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CoUege  of  Mv^itmn&  anb  ^urgeong 

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CLINICAL  MANUAL 


OF 


MENTAL     DISEASES 


THE  OLD  TREATMENT  AND  THE  NEW. 


/■'rontis/ieci't 


V--.  . 


CLINIC 


NUAL 


MENTAL    DI 


for  ipractttioners  anb  Stubente. 


BY 


A.  CAMPBELL  CLARK,   M.D.,  F.F.P.S.G., 

Mackintosh    I,ecturer    on    Psychological    Medicine,  St.   Mungo's  College 
Glasgow  Medical  Superintendent  of  I^anark  County  asylum,  Hartwood. 


NEW    YORK: 
WILLIAM    WOOD    &    COMPANY 

I8q8. 


PREFACE 


Why  a  preface  begins  with  an  apology,  I  have  never  been 
able  to  understand.  A  book  must  stand  or  fall  very  much 
on  its  own  merits,  and  an  apology  will  not  help  it.  I  am 
not  concerned,  therefore,  to  offer  an  apology  for  the  appear- 
ance of  this  work ;  but  a  certain  explanation  is  due  to  those 
for  whom  it  has  been  written. 

A  search  may  be  made  in  its  pages  for  pathological 
teaching.  Of  such  there  is  none.  The  pathology  of  in- 
sanity has  yet  to  be  written.  We  have  had  to  retrace  our 
steps  in  this  respect,  and  begin  de  novo  with  what  in  bac- 
teriology are  called  '  control  experiments ' ;  in  other  words, 
we  required  to  be  certain  of  normal  data  before  we  could 
determine  what  are  abnormal.  Dr.  Robert  Hutchison 
obtained  from  the  post-mortem  room  of  the  Royal  Infirmary, 
Edinburgh,  reputedly  normal  brains.  From  these  he  cut 
sections  and  examined  them,  and  he  discovered  in  them, 
what  have  hitherto  been  regarded  as  pathognomonic  of  some 
forms  of  insanity — vacuolation  of  nerve  cells,  pigmentary 
degenerations,  etc. 

It  is  true  that  excellent  and  valuable  work  in  brain  histology 
has  been  done  by  Golgi,  Ramon  y  Cajal,  Bevan  Lewis,  Batty 
Tuke,  Wiglesworth,  Ford  Robertson,  and  a  host  of  others  too 
numerous  to  mention  ;  but  a  sifting  process  is  now  necessary, 


vi  PREFACE 

and  some  articles  of  pathological  belief  require  to  be  dis- 
carded before  a  process  of  reconstruction  is  begun. 

The  preparation  of  this  work,  which  is  necessarily  limited 
in  its  contents — published  as  it  is  for  general  practitioners 
and  students — was  undertaken  because  of  the  new  regulations, 
which  make  mental  diseases  a  compulsory  subject  of  medical 
study.  An  examination  in  this  subject  is  not  required  by  all 
examining  bodies ;  but  all  are  agreed  that  the  clinical  study 
of  mental  diseases  is  most  important. 

I  have  to  acknowledge  the  valuable  assistance  received 
from  Dr.  T.  Alf.  Beadle  in  correcting  proofs  with  me,  in 
collecting  clinical  material,  and  in  other  ways.  To  Miss 
Julia  F.  Ferguson  and  Dr.  Charles  A.  Bois  I  am  indebted  for 
the  careful  preparation  of  the  Index,  and  to  Dr.  Bois  still 
further  for  help  in  other  directions. 

A.  CAMPBELL  CLARK. 


CONTENTS 


CHAPTER  I'AGE 

I.    MENTAL    CONSTITUTION                   -                   -                   -                   -  g 

II.    MENTAL    CHARACTER MENTAL    HEALTH                   -                   -  21 

III.  SLEEP INSOMNIA    AND    ITS    TREATMENT                 -                   -  33 

IV.  THE      EXAMINATION     OF      MENTAL     CASES — -DIAGNOSTIC 

CHARACTERS    OF    INSANITY                    -                   -                   -  47 

V.    CAUSATION PROGNOSIS GENERAL      PRINCIPLES      OF 

TREATMENT                 -                   -                   -                   -                   -  68 

VI.    GENERAL    PRINCIPLES    OF    TREATMENT    (coiltiuued)              -  8g 

VII.    MELANCHOLIA KATATONIA CATALEPSY                   -                   -  lOI 

VIII.    PARTIAL  INSANITY CHRONIC  PROGRESSIVE  DELUSIONAL 

INSANITY    ------  125 

IX.    MANIA — ITS    VARIOUS    FORMS      -                   -                   -                   -  14^5 

X.    ANERGIC    STUPOR,    DEMENTIA,    INSANITY    OF    MASTURBA- 
TION,   MORAL    INSANITY,    IMPULSIVE    INSANITY           -  173 
XI.    GENERAL    PARALYSIS    OF    THE    INSANE     -                   -                   -  197 
XII.    EPILEPTIC    INSANITY        -----  224 

XIII.    EVOLUTIONAL    AND    DISSOLUTIONAL    TYPES            -                   -  25I 

XIV.    INEBRIETY ALCOHOLIC     INSANITY OTHER     FORMS     OF 

INEBRIETY SYPHILITIC    INSANITY                     -                   -  280 

XV.    INSANITY     OF     PREGNANCY PUERPERAL     INSANITY IN- 
SANITY   OF    LACTATION           -                   -                   -                   "  3^1 
XVI.    PUERPERAL     AND     ALLIED      INSANITIES     {contiuued) IN- 
SANITY   OF    LACTATION           -                                      -                   -  34O 


CONTENTS 


CHAPTER  J'AGE 

XVII.    CONSECUTIVE    OR    CONCOMITANT    INSANITIES       -  -       360 

XVIII.    MENTAL     DEVELOPMENT     RETARDED      OR      IMPAIRED    AS 

DISTINGUISHED     FROM     IMBECILITY    AND     IDIOCY 

THE    BACKWARD    AND    FEEBLE-MINDED  -  -       39I 

XIX.    IDIOCY    AND    IMBECILITY  .  .  -  .       ^l5 

XX.    THE     LEGAL    AND    CIVIL    ASPECTS     OF    MENTAL    DISEASE 

THE   FUNCTIONS    OF    MEDICAL    MEN    IN    RELATION 

TO    THESE  ...  -  -       ^28. 

INDEX    -  -  -  -  -  -  -       479 


CLINICAL  MANUAL  OF  MENTAL 
DISEASES 


CHAPTER   I. 

MENTAL  CONSTITUTION. 

An  elementary  knowledge  of  mental  constitution  is  the  necessary  founda- 
tion of  a  knowledge  of  mental  disease — -Mental  development  in  the 
child — The  senses  first  in  evidence — Defects  of  sensation  in  idiots — 
Perception  of  distinct  sensations — ;Time  sensation — Space  sensation — 
The  senses  aid  each  other — The  genesis  of  the  emotions — Inquisi- 
tiveness  and  acquisitiveness  — Imitation  the  beginning  of  volition — 
The  evolution  of  the  faculty  of  language — The  memory — The  moral 
sense,  precocious  in  some,  retarded  in  others  —  Sensation  and 
voluntary  movement  connect  mind  with  the  environment — Mental 
constitution,  its  component  parts  and  their  attributes — Mental  en- 
dowments— Musical,  artistic  and  poetic  faculties,  sense  of  humour, 
and  imagination. 

To  the  question.  What  is  metaphysics  ?  a  shrewd  Scotch  rustic 
repHed,  '  When  the  person  wha  Hstens  disna  ken  what  the 
person  wha  speaks  says,  and  when  the  person  wha  speaks- 
disna  ken  what  he  says  himsel',  that's  metapheesics.'  This 
broad-humoured  tilt  at  the  clashing  contentions  of  philo- 
sophers, among  whom  his  own  countrymen  were  not  the 
least  conspicuous,  had  a  vein  of  truth  in  it. 

To  the  average  student  the  study  of  mind  is  wearisome 
and  unprofitable,  but  every  subject  of  study  must  have  a 
foundation,  and  an  elementary  knowledge  of  mental  con- 
stitution is  the  necessary  foundation  of  a  knowledge  of  mental 
disease. 

The  simplest  way  to  approach  the  study  of  mind  is  to- 
study  its  beginnings  in  the  child.  When  this  is  done^ 
the  s:eneral  features  in  relation  to  each  other  can  be  better 


lo  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

appreciated.  To  begin  then,  see  what  child-life  reveals  to 
us.  First,  there  is  a  reflex  instinctive  organism,  and  nothing 
more.  It  neither  sees  nor  hears  at  first.  The  lines  of  sensa- 
tion are  completely  laid  at  birth  up  to  the  cerebrum,  but 
connecting  links  are  incomplete, 
_4  Very  quickly  taste  and  smell  are  manifested ;  it  may  be  in 
two  or  three  days  at  latest.  At  different  times  in  different 
individuals,  just  like  the  teeth,  do  the  other  senses  develop, 
and  yet  their  exercise  is  still  of  the  most  rudimentary  kind. 
The  whole  range  of  sensation  is  a  wide  one,  and  the  educa- 
tion of  the  senses  is  a  very  elaborate  process.  The  senses 
must  have  practice,  for  use  increases  rapidity  and  accuracy 
of  transmission,  and  the  qualities  of  sensation — e.g.,  form, 
colour,  sound,  pitch,  heat,  cold,  and  other  discriminations — 
are  the  acquired  results  of  sense  education. 

■^  I  In  the  study  of  mind,  therefore,  you  begin  with  sensation  ; 
you  inquire  as  to  the  efficacy  of  the  special  senses,  and  you 
note  their  deficiencies.  In  idiots  you  will  often  observe 
defects  of  sensation,  and  one  form  of  idiocy  is  known  as 
'  idiocy  by  deprivation  of  special  senses.' 

^  There  comes  a  time  very  early  in  child-life  when  the  func- 
tion of  sensation  is  so  far  perfected  that  the  child  is  able  to 
perceive  one  sensation  as  distinct  from  another,  not  only 
because  the  one  succeeds  the  other  (time  perception),  but 
because  the  sources  and  directions  of  sensations  are  different 
(space  perception). 

Preyer's  observations  with  regard  to  tijne  and  space  are  as 
follows  :  (a)  Time.  If  two  simple  sensations,  two  lights,  two 
tones,  two  pricks,  are  apprehended  as  twofold,  then  the  child 
apprehends  one  of  them  after  the  other ;  the  difference 
between  them  is  time,  (b)  Space.  Relations  of  space  the 
child  learns  through  his  own  experience  exclusively,  through 
failures  in  seizing  objects,  errors  of  vision,  hits,  falls,  move- 
ments of  the  eyes  and  head,  and  through  the  perception  that 
objects  are  brighter  or  darker  as  they  are  near  or  distant. 

A  very  important  point  for  you  to  consider  is  that  the 
senses  aid  each  other.  Touch  is  very  useful  in  this  way  ; 
and  it  is  a  curious  illustration  of  how  a  good  habit  becomes 
a  bad  one,  that,  when  objects  are  exhibited  in  public,  a  con- 


/a  l^  "^  *^^'  **-VwdXt 


MENTAL  CONSTITUTION 


spicuous  notice  has  to  be  placed  bearing  the  words  '  Do  not 
touch.'     This  tendency  to  touch  what  can   be  appreciated  ( 
perfectly  well  by  the  aid  of  sight  alone  is  a  habit  continued 
from  childhood,  when  the  education  of  sight  was  frequently 
assisted  on  appeal  to  the  sense  of  touch. 

The  genesis  of  the  emotions  is  evident  at  an  early  stage  of 
child-life.  In  animals  the  emotions  are  unrestrained,  for 
intellect  is  nil  or  rudimentary,  and  the  same  may  be  said  of 
emotions  in  idiots,  wljo  are  the  nearest  approach  in  the  human 
creation  to  the  animal  type.  The  emotions  most  noticeable 
in  either  the  child  or  animal  are  fear,  anger,  love,  jealousy, 
hatred.  In  the  child,  however,  sensation  and  emotion  are 
only  the  beginnings  of  progressive  mental  evolution.  It 
passes  from  lower  to  higher  levels  of  development,  leaving 
the  idiot  and  the  animal  far  below. 

The  child  soon  ceases  to  be  afraid  when  sensations  of 
the  same  kind  are  frequently  repeated.  In  the  normal  child 
wonder  or  astonishment,  and  then  curiosity,  take  the  place 
of  fear.  Inquisitiveness  and  acquisitiveness  now  come  into 
play,  and  the  march  of  intellect  has  begun. 

When  is  there  any  evidence  in  the  child  of  the  exercise  of 
will  ?  It  is  generally  regarded  that  the  appearance  of  imita- 
tive movements  is  the  first  evidence.  A  child  cannot  imitate 
without  having  some  previous  idea  of  the  movement.  As 
Preyer  puts  it,  he  must  have  an  image  of  the  movement  in 
his  mind.  He  must,  therefore,  initiate  a  movement  to  corre- 
spond with  the  image,  and  this  means  an  effort  of  will.  The 
ladder  of  progress  is  here  manifest — first,  sensations  from 
which  arise  perceptions,  then  memories  (images  of  move- 
"ments),  ideas,  and  will. 

A  child  thinks  at  first  without  words ;  language  is  a 
specially  human  function,  and  it  comes  later.  Cause  and 
effect  have  puzzled  his  little  mind,  and  conclusions  right  or 
wrong  have  been  deduced  long  before  he  can  think  in  words 
or  speak  them.  True,  there  is  a  language  of  expressions, 
of  sounds  and  signs,  which  his  imitative  faculty  enables  him 
to  make  use  of,  and  which,  in  proportion  to  its  fulness  and 
variety,  indicates  further  intellectual  development. 

The  time  when  true  articulate  speech  is  first  uttered  varies 


12  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

in  different  individuals  ;  it  may  be  in  the  second  year,  or  not 
till  the  fourth.  Some  children  in  whom  speech  has  been 
delayed  have  been  known  to  utter  a  short  sentence  as  their 
first  contribution,  showing  that  the  faculty  of  language  had 
been  progressing  for  some  time,  although  the  motor  mechanism 
gave  no  sign. 

The  memory  of  the  child,  so  far  as  we  can  hark  back  in 
our  own  experience,  may  be  traced  to  about  the  fourth  year ; 
that  is  to  say,  we  can  remember  things  as  far  back  ;  but  the 
W-child  could  never  learn  what  it  has  learned  up  to  that  time 
'  without  memory  of  some  kind,  however  primitive.  Yet  it  is 
only  when  the  child  is  conscious  of  his  own  identity,  when 
ideas  take  possession  of  his  mind,  and  when  speech  comes  to 
him,  that  memories  that  are  lasting,  and  can  be  referred  to 
afterwards,  begin  to  be  formed. 

Preyer  observes  that  the  child's  memory  in  any  single 
department  of  sense  is  weak,  and  illustrates  this  by  reference 
to  an  observation  made  by  Professor  Baldwin,  of  Toronto, 
as  follows  :  '  The  nurse  of  a  child  six  and  a  half  months  old, 
with  whom  the  child  had  lived  for  five  months,  left  it  for 
three  weeks,  and  was  instructed  upon  her  return  (i)  tO' 
appear  in  her  ordinary  dress,  but  without  speaking,  (2)  then 
to  speak  in  her  ordinary  manner  without  being  seen,. 
(3)  finally  to  appear  and  sing  a  song  that  the  child  had  not 
heard  during  the  three  weeks  of  the  nurse's  absence.  At 
the  first  the  child  stared  with  a  questioning  look,  but  gave 
no  sign  of  recognition  and  no  sign,  to  be  sure,  of  fear  or 
antipathy  as  at  the  sight  of  a  stranger.  At  the  second  there 
was  no  recognition  ;  the  voice,  therefore,  did  not  suffice.. 
At  the  final  the  recognition  was  complete.'  And  so  ever 
through  life  one  sense  impression  aids  another  where  memory 
is  weak  or  at  fault. 

The  origin  of  a  moral  sense  has  no  certain  period,  and 
precocity  is  rather  a  bad  than  a  good  sign.  Clouston  quotes 
the  case  of  a  small  boy  whose  conscientiousness  was  most 
acute,  and  who  balanced  the  pros  and  cons  of  moral  obliga- 
tion and  duty  with  a  fineness  of  point  that  was  really  absurd,, 
and  yet  the  same  boy  a  few  years  later  was  a  m.oral  imbecile. 
My  experience  is  that  a  late  development  of  the  moral  sense,. 


MENTAL  CONSTITUTION  13 

in  many  cases,  is  safer  than  a  very  early  one.  It  is  often 
retarded  by  fear  and  injudicious  upbringing. 

The  outhne  sketched  here  gives  the  chain  of  sequences  in 
the  mental  development  of  the  child,  beginning  with  sensa- 
tion, and  ascending  upwards  till  the  moral  faculty  appears. 
The  beginnings  are  established,  but  the  complicated  consti- 
tution of  mind  is  not  yet  reached ;  nor  can  anyone  predict 
what  the  character  of  the  coming  man  or  woman  will  be. 
We  are  accustomed  to  say  that  the  child  is  the  father  of  the 
man,  and  to  predict— seeing  that  we  know — that  because 
Washington  never  told  a  lie,  and  'never  saw  fear,'  that  he 
was  sure  to  become  a  great  man  ;  but  there  is  nothing  more 
uncertain  than  the  precise  differentiation  of  character  that  will 
unfold  itself  during  later  childhood,  puberty  and  adolescence. 

Sensation  may  properly  be  regarded  as  the  starting-point 
of  mental  development,  and  after  it  the  higher  centres, 
emotion,  intellect,  volition  and  moral  faculty  are  slowly, 
laboriously,  but  surely  evolved.  This  process  of  evolution 
is  very  interesting.  The  idea  that  a  man's  mind,  character 
and  habits  are  the  result  of  a  multitude  of  experiences  acting 
on  a  plastic  organism,  that  these  have  a  time  relation  to 
each  other,  that  the  first  are  most  firmly  rooted  in  memory, 
and  the  last  the  least  persistent — this  idea,  I  say,  has  given 
rise  to  speculations  regarding  mental  disease  of  a  very 
practical  kind. 

If  mental  disease  is  a  process  of  dissolution,  does  it  reverse 
the  order  of  evolution  and  wipe  out  the  last  experiences,  the 
last  acquired  habits,  first  ?  In  the  study  of  mental  disease 
there  is  much  to  support  this  conclusion,  and  much  to  throw 
doubt  on  it.  In  the  insanity  of  old  age  it  is  quite  common 
to  find  the  patient  enacting  the  life  of  forty  or  fifty  years  ago. 
Ask  that  old  woman  who  bustles  about  with  tottering  steps 
and  waning  sight  what  she  is  doing ;  her  answer  is,  '  Making 
Jim's  supper.'  There  is  no  fire  or  cooking  utensil  near,  her 
husband  died  twenty  years  ago,  but  she  thinks  she  is  again 
a  young  married  woman  surrounded  by  her  children,  and,  if 
you  ask  her  age,  she  will  tell  you  she  is  twenty-five. 

Not  long  ago  I  attended  an  old  lady  whose  brain  functions 
had  gradually  become  obliterated  till  only  the  organic  and 


14  CLINICAL  MANUAL  OF  MENTAL  DISEASES 


the  sense  of  taste  remained.  The  first  sense  to  develop,  it 
was  the  last  remnant  of  her  mental  evolution.  I  might 
illustrate  this  point  further,  but  there  is  no  occasion.  I 
have  said,  however,  that  there  is  much  to  throw  doubt  on 
this  theory  of  the  sane  evolution  and  insane  dissolution,  and 
it  is  seen  in  general  paralysis  of  the  insane,  where  the  order 
of  dissolution  is  not  strictly  reversed.  The  habit  of  hoarding 
rubbish — which  is  a  boy's  habit — is  an  early  symptom,  and 
appears  before  the  dissolution  of  habits  and  memories  ac- 
quired in  later  life. 

These  observations  are  interesting  as  showing  how  really 
useful  some  knowledge  of  mental  development  and  the  con- 
stitution of  mind  must  be  if  we  would  intelligently  study 
mental  disease  ;  but  I  promised  at  the  outset  to  deal  in  a 
simple  manner  with  the  subject,  and  a  few  words  are  all  that 
need  be  spoken  regarding  mental  constitution  in  man. 

From  what  has  been  already  said,  it  is  evident  that  the 
foundation  of  mental  constitution  must  be  sensation.  Before 
ever  there  was  a  mind,  sensation  was  there,  its  lines  laid  in 
all  directions.  Extending  beyond  its  centres  are  gradually 
opened  up  the  lines  of  mental  communication,  as  a  result  of 
sensations,  these  flooding  centres  of  taste,  smell,  sight,  hearing 
and  touch,  until  at  last  these  lines  of  mental  communication 
open  outwardly  into  the  voluntary  motor  system,  and  the 
circuit  is  completed  thus  :  sensation,  mind,  voluntary  move- 
ment, environment. 

Sensation  and  voluntary  motion,  therefore,  connect  mind 
with  its  environment.  In  this  way  man  receives  impressions 
from  without,  and  responds  to  them. 

The  mental  constitution  has  four  parts  that  are  quite 
familiar  :  (i)  the  Intellect ;  (2)  the  Emotions ;  (3)  the  Moral 
Nature ;  (4)  the  Will  and  Impulses.  Unfortunately,  this 
classification  and  its  further  analj^sis  is  not  treated  with  the 
respect  due  to  its  age  by  those  who.  indulge  in  modern  specu- 
lations ;  but  it  is  convenient  and  useful  for  medical  practice, 
and  a  more  abstruse  treatment  of  the  subject  will  not  simplify 
the  study  and  diagnosis  of  mental  disease. 

The  intellect  is  a  term  synonymous  with  '  thinking  faculty  ' 
or  '  reasoning  powers.'     These  powers  have  been  variously 


MENTAL  CONSTITUTION  15 

enumerated.  I  propose  to  name  five  :  Attention,  Sense  Per- 
ception, Apperception,  Memory,  Language. 

The  faculty  of  attention  is  here  recognised  because  of  its 
importance  as  an  object  of  study  in  mental  disease.  By  many 
writers  it  would  be  absorbed  in  apperception  and  sense  per- 
ception ;  but  it  is  better  that  we  should  regard  it  as  standing 
by  itself,  especially  as  the  term  is  familiar  and  in  common 
use.  We  are  accustomed  to  speak  of  'fixing  our  attention,* 
'attention  wandering,'  etc.  You  will  very  frequently  find 
this  faculty  affected  in  mental  disease. 

We  may  regard  the  intellect  as  operating  under  two  different 
conditions  :  (a)  Consequent  on  sense-stimuli.  We  have  an 
example  of  it  in  the  study  of  an  object  under  the  microscope. 
This  is  sense  perception,  (b)  Independent  of  or  unaware  of 
sense  stimuli.  An  example  of  this  we  find  in  mental  abstrac- 
tion, as  in  following  out  a  train  of  thought.  This  is  called 
apperception,  and  it  is  expressed  in  these  words,  '  I  think  * 
(Kant). 

It  is  well  to  make  use  of  these  two  terms :  sejise  perception, 
a  mere  sensory  discrimination,  and  apperceptio7i,  the  exercise 
of  thought  or  understanding. 

The  remaining  two  faculties  of  intellect,  memory  and 
language,  are  most  important.  Two  kinds  of  memory  have 
been  distinguished  :  {a)  spontaneous ;  (6)  recollection  where 
the  name  or  quality  to  be  remembered  is  voluntarily  sought 
for  {vide  Maudsley,  '  Physiology  of  Mind ').  It  has  been  found 
convenient  to  speak  of  memory  cells,  in  which  impressions 
are  produced  and  can  be  reproduced  :  (a)  spontaneously,  or 
(6)  by  an  effort — recollection.  It  certainly  helps  us  very  much 
to  suppose  that  every  idea,  word,  or  other  mental  impression 
is,  so  to  speak,  photographed  in  cell  structure,  and  that  the 
■negative  impression  may  be  faint  and  transient,  or  deep  and 
lasting.     It  gives  us  a  working  conception  that  is  very  useful. 

In  its  broadest  sense  language  is  of  two  kinds  :  {a)  inarti- 
culate, or  the  language  of  sound,  signs,  and  expression ; 
(b)  articulate  language,  the  language  of  words.  The  former 
has  been  called  emotional  or  animal  language ;  the  latter 
intellectual  language,  and  it  is  really  a  branch  of  the  memory 
faculty. 


i6  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

Ideas  are  the  result  of  perceptions  and  apperceptions,  and 
may  be  abstract  (size,  colour,  kindness,  cruelty)  or  con- 
crete (man,  elephant,  ship,  steam-engine). 

We  are  all  familiar  with  the  phrase  association  of  ideas. 
What  does  it  mean  ?  Simply  this — that  one  idea  suggests 
another  spontaneously  (spontaneous  memory).  According 
to  the  education  or  experience  of  any  man  is  the  amount  of 
variation  possible.  To  a  cannibal  the  sight  of  a  white  man 
may  suggest  danger  or  something  to  eat ;  but  to  another 
white  man  it  would  suggest  companionship,  intercourse, 
news,  and  various  other  ideas.  In  either  case  the  ideas  are 
reasonable  and  natural  in  their  association,  according  to  the 
experience  and  manner  of  life  of  the  individual ;  they  are 
quite  intelligent,  and  we  call  them  coherent. 

The  following  may  be  taken  as  a  practical  lesson  of 
importance  in  this  connection  :  A  man  hastening  to  catch 
a  train  sees  the  signal  fall,  and  immediately  puts  on  more 
speed.  The  ideas  here  are  natural  and  coherent ;  but  if  the 
falling  of  the  signal  caused  him  to  stand  stock  still  from  fear, 
because  it  suggested  the  idea  that  he  was  to  be  shot,  the 
association  of  ideas  would  be  insane,  and,  having  no  rational 
connection,  would  be  called  incoherent.  It  has  been  reasoned 
that  the  incoherence  of  the  insane  is  more  apparent  than  real, 
for  words  and  ideas  suggest  others,  no  matter  how  absurd 
the  association  may  be  to  the  ordinary  observer. 

Thus  briefly  an  outline  of  the  intellectual  sphere  has  been 
given,  and  more  briefly  still  we  must  now  consider  the 
emotional.  Man  feels  as  well  as  thinks.  The  pleasures  and 
pains  of  his  life ;  the  passions  of  joy,  anger,  grief,  hate ;  the 
instincts  (love  of  life,  or  instinct  of  self-preservation,  the 
maternal  instinct,  the  sexual  instinct),  are  registered  in  the 
emotional  sphere.  The  range  of  emotional  activities  is  so 
great  that  much  confusion  has  arisen,  and  under  the  head 
of  emotions  are  classed,  often  with  little  discrimination, 
emotions,  feelings,  affections,  instincts,  appetites,  desires. 
Where  others  have  failed  to  differentiate  clearly,  we  may  be 
excused  if  we  pass  on  to  one  phase  only  of  the  question,  and 
that  a  most  important  one. 

Feeling  proper  is  that  faculty  which  registers  pleasure  or 


MENTAL  CONSTITUTION  17 

displeasure  (misery).  Whatever  our  sensations  or  thoughts, 
the  register  of  feehng  responds  to  them.  The  two  extremes 
are  conscious  pleasure  and  conscious  displeasure  (misery)  ; 
but  between  these  extremes  there  are  degrees,  and  in  the 
register  there  is  a  point  mid-way  where  the  state  of  feeling 
is  neutral,  indicating  neither  pleasure  nor  misery.  Somewhere 
near  this  neutral  point  is  the  registered  state  of  feeling  of 
average  man.  Clouston  says  that  the  normal  man  has  a 
conscious  sense  of  well-being,  but  this  is  scarcely  accurate. 
It  is  certainly  not  Correct  to  say  that  a  normal  man  is  always 
or  nearly  always  consciously  in  a  state  of  well-being ;  that 
he  is  always  in  '  good  form  '  and  conscious  of  it,  or  that  he 
feels  that  everything  is  couleur  de  rose  with  him.  As  a  matter 
of  fact,  and  an  appeal  to  the  average  experience  of  mankind 
will  confirm  this  statement,  the  average  state  of  feeling  is 
somewhat  neutral  and  sub-conscious.  If  depression  indicates 
an  abnormal  state  of  mental  health,  why  does  exaltation, 
which  is  its  opposite,  also  indicate  the  same  ?  If,  as  Clouston 
says,  the  sense  of  well-being  is  an  index  of  good  mental 
health,  how  about  the  exaltation  of  the  general  paralytic, 
and  why  are  some  patients  so  content  and  bright,  so  cheerful 
and  unrepining,  while  others,  suffering  from  as  acute  physical 
disease,  are  just  the  opposite  ?  If  an  explanation  will  help 
us,  even  though  it  is  a  theoretical  conception,  I  would 
suggest  that  the  anatomical  basis  of  feeling  has  its  own 
vascular  area,  which  in  some  individuals  is  more  readily 
controlled  than  in  others,  just  as  fear  blanches  the  cheek  and 
shame  flushes  it  in  some  and  not  in  others,  and  that  the 
degree  of  ebb  and  flow  indicates  the  degree  of  depression  on 
the  one  hand  and  exaltation  on  the  other. 

A  short  statement  requires  also  to  be  made  regarding  the 
will  and  impulses.  Here  also  modern  philosophy  has  been 
making  ravages.  Will  is  regarded  as  the  result  of  more  or  less 
opposing  forces,  and  the  old-fashioned  diagram  in  mechanics, 
illustrating  the  parallelogram  of  forces,  might  just  as  well  be 
used  to  illustrate  the  theory  of  mental  forces  more  or  less 
opposed  to  each  other,  resulting  in  one  force  only,  a  com- 
promise between  the  two  or  more  contending  forces.     The 

2 


i8  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

one  resulting  force  is  called  Will,  and  is  regarded  merely  as  a 
sequence,  not  as  a  separate  factor  at  all. 

Again  I  propose  to  follow  the  old  way,  and  speak  of  Will 
as  a  faculty  b}-  itself,  presiding  over  the  other  mental  faculties. 
It  is  convenient  for  clinical  practice  to  think  of  it  thus 
guiding  their  exercise,  determining  conduct,  and  regulating 
impulses.  Impulses  spring  from  emotion  or  moral  senti- 
ment. Will  is  the  judge  before  whom  apperception  (the 
advocate)  pleads  ;  but  it  may  be  swayed  by  emotion. 

We  next  consider  the  question,  What  is  the  relative 
superiority  of  will  over  impulse  ?  And  a  brief  reflection  is 
enough  to  decide  that  there  must  here  be  a  sliding-scale. 
There  can  be  no  fixed  standard,  for  the  force  of  impulse 
depends  on  the  susceptibility  of  the  individual  to  tempta- 
tion, and  to  some  temptations  more  than  others,  as  also  to 
temptations  more  powerful  at  particular  times. 

Speaking  generally,  it  is  quite  understood  that  Impulse 
craves  and  strives  for  outward  expression,  and  Will  grants 
free  course  to  impulse,  or  pulls  the  reins  of  inhibition  (self- 
control).  These  two  have  been  compared  to  a  driver  and  a 
horse.  Will  permits  or  controls  just  as  the  driver  permits 
or  controls :  but  where  impulses  by  frequent  indulgence 
become  strong,  the  will  is  correspondingly  weakened.  Will 
ought  to  be  supreme  and  unwavering.  Self-control  is  a 
necessity  of  a  healthy  mind. 

Without  discussing  the  origin  of  a  moral  nature,  we  accept 
the  fact  of  a  moral  feeling  or  sense  occupying  a  place  in 
every  healthy  mind.  We  recognise  that  in  the  normal  mental 
constitution  there  is  a  knowledge  of  moral  distinctions,  of 
right  and  wrong  ;  that  there  is  a  sense  of  responsibilit}-, 
obligation,  or  duty,  and  analyze  it  as  we  may,  that  there  is 
such  a  voice  as  conscience.  In  some  the  moral  nature  is 
rigid,  in  others  it  is  more  elastic,  much  of  this  depending  on 
inheritance,  education,  and  the  social  environment. 

The  description  of  mental  constitution  outlined  here  would 
not  be  complete  were  we  to  leave  out  of  consideration  certain 
mental  endowments  which  adorn  the  mental  constitution, 
and  are  not  limited  to  any  particular  sphere  of  mental 
exercise. 


MENTAL  CONSTITUTION  19 

These  are  the  musical  faculty,  the  artistic  faculty,  the 
poetic  faculty,  the  sense  of  humour,  and  the  imagination. 
How  much  they  are  dependent  on  intellect,  and  how  much 
on  emotion,  we  need  not  pause  to  consider. 

The  musical  faculty  requires  a  musical  ear,  a  true  sense  of 
discords  and  harmonies,  a  delicate  appreciation  of  rhythm, 
pitch,  and  time.  It  requires  to  be  cultivated  by  the  eye,  the 
ear,  and  the  touch,  and  by  intellectual  study.  Music  sways 
feeling  and  emotion,  excites  pain,  pleasure,  rapture,  exalta- 
tion, and  disperses  waves  of  sense  and  motion  through  the 
nervous  system. 

In  like  manner  the  artistic  faculty  calls  forth  the  exercise 
of  many  mental  and  nervous  functions,  for  it  takes  note  of 
light  and  shade,  form,  proportion,  perspective,  expression. 
It  also  speaks  to  intellect  and  emotion,  educating  intellect 
and  stimulating  emotion. 

The  poetic  nature  has  its  creative  and  receptive  side. 
While  few  are  poets,  many  are  receptive  and  appreciative 
of  poetry.  Culture  and  experience  aid  the  receptive  more 
than  the  creative  faculty.  The  poetic  nature  is  eminently 
sensitive,  and  is  capable  of  intense  feeling  and  emotional 
excitement. 

The  sense  of  humour  is  native  in  most  persons,  and  it  can 
be  fostered  and  quickened  by  education  and  exercise.  It  is 
a  boon  to  man  and  a  safeguard  to  mental  health.  A  mind 
devoid  of  this  sense  lacks  a  safety-valve,  and  inclines  more 
readily  to  be  morbid. 

The  faculty  of  imagination  is  creative.  By  its  exercise 
mental  pictures  arise,  and  new  presentations  of  ideas.  This 
is  well  illustrated  in  day-dreaming.  Here  revel  the  poet,  the 
artist,  and  the  musician.  The  philosopher  and  the  scientist 
find  their  highest  intellectual  pleasures  in  the  realms  of 
imagination.  Mind  without  some  degree  of  imagination 
cannot  be  conceived.  The  play  of  fancy  of  which  it  is 
capable  is  endless.  Even  the  simplest,  most  illiterate  toiler 
has  his  daydreams.  Shut  off  mind  from  its  environments, 
and  yet  a  man  is  not  limited  to  his  old  stock  of  ideas.  He 
creates  new  combinations,  calls  up  memories,  creates  new 
ideas,  and  transports   himself  into   relation  with   new   per- 

2 — 2 


re 


20  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

sonalities.  The  faculty  of  imagination  has  considerable  play 
in  some  individuals,  and  where  its  range  is  limited,  either  by 
inherent  defect  or  by  wholesome  restraint,  a  man  is  regarded 
as  'level-headed  '  or  '  matter-of-fact.' 

Briefly,  then,  we  ha\-e  here  reviewed  the  features  of  the 
mental  constitution  which  require  to  be  recognised,  and  we 
next  proceed  to  consider  mental  character,  which  is  the  out- 
come of  it,  and  gives  individuality  to  man. 

For  more  intimate  knowledge  of  the  subject,  the  following 
works  may  be  consulted  :  Maudsle}-,  '  Ph3^siology  of  Mind ' ; 
Hyslop,  'Mental  Physiologj' ' ;  Ladd,  'Physiological  Psy- 
cholog}' ' ;  Ziehen,  '  Physiological  Psychology  ' ;  Kirchner, 
'  Manual  of  Psychology.' 


y4/ 


/ 


"7 


CHAPTER  II. 

MENTAL  CHARACTER.— MENTAL  HEALTH. 

Mental  character,  the  physiology  of  mind — Individuality  :  each  man's 
mind  is  a  law  unto  itself— Mental  character  determined  by  the  law 
of  individuality  which  is  affected  by  (a)  evolution,  (d)  dissolution, 
(c)  environment — These  explained — Mental  health — How  it  is  main- 
tained, and  how  disturbed — Mental  hygiene. 

That  which  makes  man  most  interesting  —  his  mental 
character — now  comes  under  consideration.  All  men  have 
essentially  the  mental  constitution  which  has  just  been 
described,  but  mental  function  is  very  different  in  different 
individuals.  Of  the  genius  and  the  clodhopper  it  can  be  said 
that  they  are  both  gifted  with  senses,  intellectual  faculties, 
emotions,  etc.,  just  as  they  are  gifted  with  organs  of  circula- 
tion and  muscular  systems ;  but  how  different  the  results  ! 

We  may  speak  of  mental  constitution  as  the  anatomy  of 
mind,  and  of  mental  character  as  the  physiology  of  mind,  or 
of  the  two  as  the  producer  and  the  products.  It  goes  with- 
out saying  that  the  revelations  of  man's  mind  give  us  a 
man's  character.  These  revelations  are  manifold,  and  we 
judge  sometimes  by  what  he  does  not  express  as  well  as  by 
what  he  does  express. 

It  also  goes  without  saying  that  no  two  men  are  precisely 
alike  in  character — not  even  twins.  The  individuality  of  a 
man  is  not  so  much  in  his  physical  features  as  in  his  mental 
character. 

If  the  labourer  whose  imagination  does  not  rise  above  the 
level  of  his  daily  toil,  whose  ideas  are  limited  to  his  pickaxe 
and  shovel,  his  weekly  wage,  his  pipe  and  grog,  should  to- 
morrow begin  to  recite  poetry,  or  even  the  merest  doggerel, 
you  would  recognise  a  false  note  in  his  individuality  ;  and  if 


CLINICAL  MANUAL  OF  MENTAL  DISEASES 


the  cultured  student,  the  budding  genius  of  poetry,  should 
to-morrow  descend  to  doggerel  and  mediocrity,  you  would 
recognise  a  false  note  there  also. 

The  diversities  of  individual  character  have  no  limit. 
There  is  to  be  found  a  type  of  diffidence  and  self-distrust  as 
opposed  to  a  type  of  self-assertion  and  self-sufficiency.  You 
recognise  also  a  type  which  is  cynical,  critical,  argumenta- 
tive ;  and  its  opposite,  which  is  ready  to  concede  almost 
anything  for  the  sake  of  peace.  These  sufficiently  indicate 
that  there  is  a  mental  individuality  which  marks  out  one 
man  clearly  from  another,  and  this  mental  individuality  may 
be  thus  defined  :  Each  man's  mind  is  a  law  unto  itself ;  what  is 
normal  in  one  man  may  he  abnormal  in  another. 

Mental  character  varies  at  different  ages  and  under 
different  conditions  in  the  same  individual,  and  it  is  deter- 
mined by  the  exercise  of  certain  laws.  First  and  most 
important  is  the  law  of  individuality,  which  is  affected  by 
three  other  laws — {a)  evolution,  (h)  dissolution,  (c)  environ- 
ment. 

The  law  of  individuality  is  not  so  rigid  that  a  man  must  of 
necessity  think  and  feel  and  act  always  in  the  same  way. 
It  is  elastic  enough  to  allow  variations  of  normal  character 
within  certain  limits.  The  emotions  of  grief  and  remorse  so 
overwhelming  at  the  present  moment  may  be  assuaged  to- 
morrow. The  shyness  and  timidity  so  distressing  at  one 
moment  may  later  give  place  to  courage  and  self-assertion. 
The  imagination,  which  in  the  morning  is  clouded,  may,  as 
the  day  advances,  brighten  and  revel  in  brilliant  ideas. 
Each  mental  character,  therefore,  has  its  limits  of  contrac- 
tion and  expansion,  and  within  these  limits  there  is  the 
condition  known  as  mental  health,  for  the  changes  which 
have  been  described  are  the  necessar\'  variations  of  a  normal 
elasticity. 

The  law  of  individuality  is  modified  by  the  laws  of  evolu- 
tion and  dissolution.  We  are  not  the  same  to-day  as  ten 
years  ago.  It  is  not  possible  for  us  to  think,  feel,  and  act  in 
the  same  way.  We  are  children  of  a  larger  growth,  of  a 
wider  horizon,  of  greater  knowledge  and  broader  sympathies. 
The  child-mind  is  microscopic,  and  exists  in  a  microscopic 


MENTAL  CHARACTER  23 

environment.  Its  intellect  is  budding,  and  life  is  charged 
with  emotions.  To  chase  a  butterfly,  pursue  a  rainbow,  or 
blow  soap  bubbles  are  the  only  objects  of  existence.  '  Suf- 
ficient for  the  day  is  the  evil  thereof.' 

While  birthdays  come  and  go,  it  is  noticed  that  the  child 
has  been  acquiring  ideas  and  forming  simple  syllogisms  not 
always  infallible  ;  that  it  has  learned  to  abstract  ideas  from 
concrete  objects,  and  to  indulge  in  little  day-dreams.  Train- 
ing begins  to  develop  habits  of  study  and  conduct,  and  the 
moral  sense  becomes  more  acute. 

At  puberty  phenomenal  changes  occur  of  a  physico-sexual 
character,  which  are  reflected  in  the  mental  character. 
There  is  generally  a  rise  of  self-consciousness  and  egotism, 
affectation  and  conceit,  and  a  gradually  increasing  sense  of 
personal  responsibility.  There  is  also  noticed  frequently  a 
shyness  of  the  male  in  the  presence  of  the  opposite  sex,  a 
disposition  to  be  opinionative,  and  to  affect  a  character  of 
manliness. 

Adolescence  is  a  more  fully-developed  stage  of  sexual 
evolution.  Increase  of  stature  is  less  marked,  and  will  cease 
in  this  stage  ;  but  the  physical  proportions  are  increased 
perceptibly  in  other  directions,  while  the  whisker  makes  its 
appearance,  and  a  more  stable  and  serious  mental  character 
is  gradually  unfolded.  There  is  still  self-consciousness  and 
egotism,  but  their  manifestations  are  less  crude  and  outre, 
the  imaginative  faculty  takes  a  wider  range,  and  the  poetic 
faculty  finds  vent  particularly  in  verses  of  amorous  expres- 
sion. That  kind  of  literature  which  pleases  the  mental 
palate  of  the  boy — stories  of  adventure  and  brave  deeds — 
gives  place  to  novels  which  quicken  the  affective  senses  and 
exalt  the  sexual  emotions. 

The  relation  of  the  sexes  is  entirely  altered  with  the 
appearance  of  puberty  and  adolescence.  Self-consciousness 
and  egotism  are  even  more  marked  in  the  girl,  and  there  is 
at  first  repulsion  which  changes  to  attraction  during  ado- 
lescence. The  opinionativeness  which  we  notice  in  the  boy 
is  still  more  marked  in  the  girl.  She  is  patronizing,  fond  of 
giving  her  opinion,  desirous  of  attracting  attention  to  herself, 
and  given  to  affectation.     There  is  in  either  sex  an  eager- 


24  CLINICAL  MANUAL  OF  MENTAL  DISEASES 


ness,  a  state  of  mental  unrest,  a  craving  after  something,  a 
pursuit  of  the  ideah 

When  a  period  of  manhood  and  womanhood  is  reached, 
about  the  age  of  twenty-four,  the  mental  character  continues 
to  increase  in  stability,  and  goes  on  increasing  for  twenty  or 
twenty-five  years.     The  period   of  evolution  which   is  past 
may  be  thought  of  rather  contemptuously.     There  may  be  a 
feeling  of  disgust  at  the  thought  of  its  vagaries,  and  there  is 
buckling  to  the  duties  of  life  in   real  sober  earnest.     The 
climacteric  period  is  the  next  stage,  and  it  appears  earlier  in 
the  female  sex  than  in  the  male.     It  marks  the  climax  of  life, 
a  period  of  critical  omen,  for  sooner  or  later  the  downward 
path  in  the  journey  is  reached.     This  period  may  be  con- 
siderably delayed  as  regards  mental  dissolution  ;  but  there 
is  no  doubt  that,  physically,  men  and  women  are  then  past 
their    best.      The    enthusiasm     and     hope     of    youth    are 
diminished.     The    pleasures    of  imagination    have    not    the 
fascination   of   earlier  years.     There   is   less    scheming    and 
planning,  less  ambition  and  hopefulness,  less  staying  power, 
a  tendency  to  mental  weariness  and   to   lack  of  sympathy 
with    new    ideas.     The   memory   is   less  receptive   and   less 
retentive  ;    the   intellectual  powers   take   a   slower  grasp   of 
new  problems,   and  there  is  a  greater  tendency  to  morbid 
reflection,   to  the  indulgence  of  '  might  have  beens.'     Last 
of  all  comes  old  age — the  period  of  second  childhood — with 
faculties  dulled,  memory  failing,  the  interests  of  life  narrowed, 
the    emotions    again    dominant,   and    self-control  weakened 
until  there  is  merely  a  reflex  of  childhood  itself. 

It  must  be  clearly  understood  that,  while  each  individual 
character  is  moulded  in  passing  through  the  epochs  of 
evolution  and  dissolution,  the  individual  is  in  some  cases 
more  plastic  than  in  others,  and  the  law  of  individuality 
expresses  itself  in  manifold  exceptions.  No  two  boys  start 
mental  life  and  develop  morally  and  educationally  on  exactly 
the  same  lines  at  precisely  the  same  pace.  They  are  in- 
herently different  at  the  outset,  and  they  are  potentially 
different  as  to  the  future.  In  one  boy  you  will  find  shyness 
all  through  childhood,  and  in  another  you  will  find  a  bold- 
ness, a  frankness,  and  a  manner  always  at  ease  with  strangers 


MENTAL  CHARACTER  25 

at  the  age  of  five,  which  may  entirely  disappear  at  the  age 
of  seven.  The  ailments  of  childhood  also  affect  the  de- 
velopment of  mental  character. 

A  child  long  coniined  to  the  sick-room  may  develop  a 
wisdom  and  quickness  of  intelligence,  the  appearance  of 
which  would  be  considerably  delayed  in  a  physically  healthy 
boy.  Then,  in  the  progress  of  education  you  also  discover 
striking  differences.  One  boy's  mind  is  from  the  first  a  good 
educational  mill :  he  is  not  a  precocious  child  by  any  means, 
but  one  of  an  adaptive  mental  habit,  who  at  the  age  of  eight 
can  write  a  respectable  letter  to  his  parents,  but  who  at  the 
age  of  twelve  has  reduced  his  educational  pace  considerably. 
Another  boy  with  a  quick  enough  intelligence,  it  may  be, 
but  difficult  to  train  and  discipline,  with  a  strong  imitative 
faculty,  an  inveterate  restlessness,  a  boy  who  is  everything 
by  turns,  and  nothing  long,  when  sent  to  school  is  kept  in 
late  to  learn  his  lessons,  plays  truant,  and  is  always  making 
excuses  to  evade  school  work.  Such  a  boy  is  educationally 
in  a  dormant  condition.  At  twelve  or  fourteen  years  of  age 
he  begins  to  settle  down  ;  the  habit  of  application  is  difficult, 
but  as  it  grows  his  mind  expands,  his  inquisitive  and  ac- 
quisitive faculties  enlarge,  and  by  the  age  of  sixteen  he  is 
alongside  his  companion,  and  thereafter  probably  forges 
ahead  of  him.  Such  examples  must  be  well  known  to  us, 
but  it  is  necessary  to  crystallize  them  here,  and  likewise  to 
crystallize  the  truth  .that  the  law  of  individuality  is  not 
superseded  by  the  laws  of  evolution  and  dissolution,  and, 
though  in  one  sense  subordinate,  it  is  in  another  sense 
determinative.  The  more  you  study  the  human  mind  and 
human  character,  the  more  you  will  perceive  the  truth  of 
what  I  have  stated,  that  each  man's  mind  is  a  law  unto  itself, 
and  that  each  case  must  be  studied  on  its  own  merits. 

The  law  of  environment  recognises  the  dependence  of 
mind  on  sensation  for  its  vitality  and  continued  healthy  1/ 
existence.  A  mind  hermetically  sealed  from  the  outside  |  / 
world  can  live  only  on  memories,  but  ceases  to  have  any 
existence  so  far  as  relation  with  the  outside  world  is  con- 
cerned. The  law  of  environment  recognises  two  kinds  of 
sense  stimuli,  (a)  organic,  (b)  non-organic,  the  one  occurring 


26  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

within  the  body,  and  the  other  occurring  outside  the  body. 
Of  organic  sensations  we  have  examples  in  sexual  excite- 
ment, uterine  sensations,  digestive  sensations,  hepatic,  renal, 
cardiac,  and  respiratory.  These  are  at  a  minimum  under 
normal  conditions.  The  sensations  of  digestion  we  are 
scarcely  conscious  of,  and  yet  they  produce  certain  recognised 
emotional  states.  Cardiac  sensations  are  not  noticeable 
under  normal  conditions,  and  the  uterine  and  sexual  are 
more  or  less  in  abeyance  except  at  periodical  times  ;  but  we 
shall  have  occasion  to  notice  the  importance  of  these  organic 
sensations  in  relation  to  disturbance  of  mental  function. 
The  non-organic  stimuli  constitute  the  chief  environment  of 
mind.  What,  then,  does  the  environment  consist  of  ?  It 
consists  of  all  Nature,  animate  and  inanimate,  and  of  all  the 
products  of  intelligence.  Everything  speaks  to  the  mind, 
for  there  is  a  form  of  expression  in  all  things.  Such  inani- 
mate objects  as  a  bare,  silent  hillside,  a  gurgling  brook,  a 
great  cairn  of  stones,  or  a  blasted  tree,  speak  to  the  mind 
with  a  meaning  of  their  own.  The  surging  and  toiling 
masses  of  a  city  population,  the  busy  hives  of  industry,  the 
dens  of  the  wretched  poor  and  criminal  classes,  convey  im- 
pressions, and  awaken  thoughts,  and  give  the  mind  abundant 
food  for  reflection.  There  is  nothing  so  small  or  so  great 
that  the  mind  cannot  be  exercised  upon  it,  and  quietly,  and 
unconsciously  it  may  be,  impressions  are  absorbed,  and  lie 
dormant  for  years.  The  environment  has  here  been  spoken 
of  in  its  widest  sense,  but  we  must  think  of  environment  as 
regards  time  and  place.  The  time  changes,  and  with  it  the 
place  changes.  The  locality  in  which  you  were  born  or 
brought  up  may  be  outwardly  much  the  same  to-day  that  it 
was  twenty  years  ago,  but  if  it  is,  the  time,  at  least,  has 
changed,  and  with  it  the  social  character  of  the  environment. 
Education  is  different,  the  books  are  different ;  new  inven- 
tions have  come  within  the  scope  of  observation  ;  the  habits 
of  the  people  have  changed,  and  their  life  has  become  trans- 
formed from  that  of  their  ancestors.  The  mind  is  fed  on  the 
conceptions  of  to-day,  and  takes  its  colour  from  the  time  in 
which  it  lives. 

The  environment  may  differ  materially  as  to  place.     One 


MENTAL  HEALTH  27 


boy  is  brought  up  among  his  native  hills,  surrounded  more 
by  the  influences  of  solitude,  the  hills  and  the  valleys  and 
the  animal  creation,  and  living  in  the  utmost  rural  simplicity. 
Another  first  sees  daylight  in  the  midst  of  a  crowded  city 
surrounded  by  the  artificial  productions  of  intelligence,  and 
masses  of  men,  women,  and  children,  his  playground  the 
streets,  and  his  views  of  life  those  of  squalor  and  wretched- 
ness, of  misery  and  crime,  sorrow  and  pain.  He  ripens  on 
a  different  pabulum,  and  is  precocious  far  in  advance  of  the 
years  of  the  simple  rustic.  Lastly,  the  environment  is 
largely  human,  and  the  action  of  mind  on  mind  does  more 
to  shape  the  human  character  than  anything  else.  The 
teaching  and  influence  of  the  parents,  brothers  and  sisters, 
playfellows,  the  schoolmaster,  of  men  and  of  books,  are  con- 
stant factors  from  the  cradle  to  the  grave,  and  exercise  a 
powerful  influence  on  the  moulding  and  development  of  the 
mental  character.  In  considering  mental  character,  then, 
the  influence  of  the  environment  must  be  carefully  inquired 
into.  The  more  we  study  it,  the  better  are  we  able  to 
account  for  differences  of  character  and  habit,  and  the  better 
are  we  able  to  understand  the  mental  history  of  the  indi- 
vidual, the  breadth  or  narrowness  of  his  mental  range,  the 
nature  of  his  feeling  and  sympathies,  of  his  religious  beliefs 
and  moral  aspirations. 

With  some  knowledge  of  mental  constitution  and  character, 
we  can  now  consider  the  question  of  mental  health.  We 
recognise  that  every  man  is  his  own  type  of  individuality, 
and  that  symptoms  perfectly  consistent  and  normal  in  one 
individual  may  be  inconsistent  and  abnormal  in  another. 
A  study  of  evolution  and  dissolution  enables  us  to  account 
rationally  for  changes  of  character  at  different  periods  of 
life,  and  the  law  of  environment  enables  us  to  account  for 
diversities  of  character  developed  under  different  external 
conditions.  What  we  would  regard  as  mental  health  in  a 
child  may  be  insanity  in  an  adult,  and  the  exhibition  of 
amorous  passion  which  in  a  young  man  may  be  normal  will 
be  inconsistent,  if  not  abnormal,  in  an  old  man.  The  first 
essential  in  the  possession  of  mental  health  is  said  by  some 
to  be  a  sense  of  well-being,  that  sense  which,  as  a  faculty  of 


28  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

our  emotional  nature,  is  quickened  in  response  to  the  general 
feeling  of  the  mind.  I  have  said  that  we  are  sometimes 
conscious  of  distinct  mental  pleasure,  and  sometimes  of 
distinct  mental  pain.  When  elated  with  victory  or  success, 
we  have  mental  pleasure ;  when  cast  down  with  grief  and 
disappointment,  we  have  mental  pain.  Our  consciousness 
is  entirely  warped  by  either  of  these  feelings  at  such  times, 
and  they  actually  dominate  our  mental  actions ;  but  between 
these  two  extremes  of  the  pendulum  there  are  grades  of  pain 
or  pleasure  down  to  a  mid-way  centre  of  an  entirely  neutral 
character,  and  this  point  at  which  the  pendulum  rests  is 
really  the  average  state  of  normal  feeling.  We  do  not  stop 
to  question  every  hour  of  our  lives,  whether  our  mental  con- 
sciousness is  happy  or  unhappy.  There  is  a  continuous 
emotional  response  to  every  phase  of  mental  action  and 
mental  life,  whether  in  the  study  or  in  the  whirl  of  business, 
in  society  or  alone  with  Nature ;  but  whatever  the  emotional 
state,  it  is  transient,  and  one  state  succeeds  another  so 
quickly  that  the  composite  result  is  all  we  need  to  care 
about.  But  when  one  string  of  emotion  vibrates  too  long 
and  intensely,  we  recognise  a  distinct  sense  of  well-being  or 
ill-being,  and  it  is  in  such  cases  that  we  require  to  consider 
the  question  of  mental  health.  The  sense  of  well-being  is 
wanting  in  the  morning  after  a  debauch,  during  a  bilious 
attack,  when  suffering  pain,  and  usually  when  affected  with 
grave  bodily  disease ;  and  when  these  disorders  or  diseases 
recur  frequently,  or  last  for  a  long  time,  there  is  danger  of 
the  mental  health  being  seriously  affected  as  well  as  the 
bodily  health.  On  the  other  hand,  while  joy  does  not  kill, 
it  may  in  excessive  amount  have  a  disturbing  effect  on 
mental  function,  and  give  rise  to  extravagances  of  feeling 
and  action  that  call  for  the  exercise  of  self-control.  Extremes 
of  feeling  are  certainly  to  be  discouraged,  the  one  as  much 
as  the  other,  for  there  is  in  mental  as  well  as  in  bodily  func- 
tion a  law  of  action  and  reaction.  You  will  sometimes  find, 
with  ladies  particularly,  a  condition  described  as  high-strung, 
a  state  in  which  the  feelings  are  extremely  sensitive  and 
responsive.  These  ladies  are  not  necessarily  of  the  hysterical 
type,  though  closely  related  to  it ;   but  they  quickly  feel  and 


MENTAL  HEALTH  29 


magnify  the  impression  of  pleasurable  experience,  transform 
it  into  extravagance  of  thought  and  action,  and  pay  for  it  in 
a  few  hours  with  an  attack  of  headache  and  depression. 
Such  ladies  should  have  been  taught  to  exercise  self-control, 
not  in  order  to  stifle  their  feelings,  but  to  moderate  them. 

You  will  find  in  practice  that  mental  depression,  this  loss 
of  the  sense  of  well-being,  is  a  frequent  condition  complicating 
bodily  disease,  and  that  there  is  an  effect  of  mind  on  body  as 
well  as  body  on  mind  that  should  be  intelligently  appreciated, 
and  this  knowledge  made  use  of  in  the  treatment  of  disease. 
A  good  deal  of  the  mental  depression  you  meet  with  in  general 
practice  is  the  reaction  of  excitement,  social,  political,  busi- 
ness, or  otherwise,  and  all  the  more  marked  and  more  liable 
to  recur  when  a  man  has  no  hobbies,  or  cannot  change 
his  attention  readily  from  one  subject  to  another.  It 
is  a  condition,  therefore,  that  you  require  to  look-out  for, 
and  while  a  man  may  put  it  down  to  his  liver,  to  want  of 
exercise,  to  too  much  smoking  or  convivial  nights,  you 
should  analyze  the  man's  manner  of  life,  in  business  and 
out  of  business,  at  home  and  in  society,  and  see  whether  the 
mainspring  is  not  mental  or  nervous,  and  the  other  conditions 
secondary. 

An  important  factor  in  determining  mental  health  is  the 
will  and  impulses.  I  shall  frequently  use  the  familiar  expres- 
sion self-control  to  indicate  the  action  of  the  will  upon  the 
impulses,  and  in  the  regulation  of  mental  action.  Self- 
control  is  a  fundamental  necessity  of  healthy  mind.  If  you 
think  for  a  moment  of  all  the  funny  and  extravagant  ideas 
that  crop  up  in  one's  mind,  of  the  absurd  speeches  that 
come,  as  we  say,  to  the  tip  of  the  tongue,  you  will  under- 
stand the  value  of  self-control.  Without  the  will  to  regulate 
and  inhibit  such  impulses  and  extravagant  thoughts,  the 
world  might  go  mad  to-morrow.  You  have  heard  of  the 
thought  or  impulse  that  seizes  some  persons  when  making 
the  ascent  of  a  monument  to  throw  themselves  down,  or 
when  on  board  ship  to  cast  themselves  into  the  sea  ;  but 
these  are  really  a  mere  fraction  of  the  insane  thoughts  and 
impulses  that  pass  through  men's  minds.  If  men  and  women 
were  to  lay  bare  their  unbidden  thoughts  without  reserve, 


30  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

the  wickedness,  immorality,  and  insanity  of  the  world  would 
be  alarming.  The  exercise  of  the  will  over  the  thoughts  and 
impulses  is,  therefore,  a  most  important  function,  and  rational 
self-control  an  absolute  necessity  of  mental  health.  I  have 
said  rational  self-control,  for  I  would  like  you  to  understand 
that  the  exercise  of  inhibition  may  go  too  far,  and  natural 
instincts  and  feelings,  as  in  the  case  of  John  Stuart  Mill, 
may  be  stifled  from  false  conceptions  of  mental  training. 
You  will  also  find  departure  from  mental  health  due  to 
excess  of  self-will,  where  the  pride  of  egoism  carries  a  man 
out  of  the  sphere  of  sanity  altogether.  I  have  known  a 
medical  student  who  had  the  sense  of  well-being  so  pro- 
nounced and  the  pride  of  egoism  so  intolerable,  and  who 
possessed  a  self-will  so  strong,  as  to  carry  him  before  he  was 
long  in  practice  into  a  state  of  incurable  insanity.  It  is 
difficult  sometimes  to  say  how  far  self-will  is  another  name 
for  strong  undermining  impulse,  and  how  far  it  is  the  result 
of  misdirected  intelligence.  Again,  a  man,  while  inhibiting 
one  impulse,  may  give  free  vent  to  another  and  a  wrong  one, 
and  thus  two  impulses  may  contend  for  supremacy  with 
unequal  force  and  unfortunate  results.  These  considera- 
tions are  convincing  proof  that  the  will  has  a  difficult  part 
to  play  in  the  sphere  of  human  action,  and  that  it  should  be 
trained  early  to  hold  the  balance  true  between  the  impulses. 

The  moral  nature  is  at  times  more  healthy  than  at  others. 
There  can  be  no  doubt  that,  under  depressing  conditions, 
and  when  the  mind  is  overwrought,  the  moral  sense  is  dis- 
turbed. It  has  been  said  that  conscience  is  the  index  of 
the  state  of  a  man"s  digestion.  The  intellect  shows  de- 
partures from  the  normal  like  the  other  faculties.  It  can  be 
exhausted  by  overwork,  and  when  so  exhausted  has  a  dis- 
turbing influence  on  the  emotions,  and  a  paralyzing  influence 
on  the  will  and  the  moral  nature,  and,  though  we  are  apt  to 
see  departures  from  mental  health  first  in  the  emotions, 
there  can  be  no  doubt  that  the  starting-point  is  frequently 
an  overwrought  intellect,  coupled  sometimes  with  excessive 
worry  and  anxiety. 

These  being  the  general  outlines  of  departures  from  mental 
health,  we  must  now  formulate  our  ideas  on  the  subject  of 


MENTAL  HEALTH  31 


hygiene.  In  the  first  place,  the  work  of  the  mind  should  be 
carefully  balanced  ;  there  should  be  no  undue  preponderance 
of  functional  activity  in  one  direction  more  than  another.  The 
bow  should  not  be  bent  till  elasticity  is  lost,  for  a  mind  that 
cannot  easily  recover  itself  after  an  excessive  strain  presents 
the  symptoms  oi  neurasthenia  (nervous  weakness).  As  I  have 
already  pointed  out,  the  mind  should  be  capable  of  being 
diverted  from  one  subject  to  another.  It  should  take  in  a 
wide  range  of  interests  and  sympathies,  and  the  man  who 
can  relieve  a  strain  in  one  direction  by  exercising  his  mind 
in  another,  and  can  in  turn  change  it  for  another  pursuit,  is 
more  likely  to  maintain  his  mental  elasticity  than  the  man 
engrossed  with  one  care  and  one  pursuit  only.  It  has  been 
said  that  it  is  not  work  that  kills,  but  worry  ;  and  I  would 
impress  on  you  the  baneful  effects  of  incessant  anxiety,  for 
it  is  because  of  the  worry  and  care  associated  with  it  that 
the  integrity  of  mental  health  suffers  more  than  from  mere 
intellectual  work  itself.  You  must  therefore  understand 
that  the  intellect  must  occupy  itself  with  more  subjects  than 
one ;  that,  next  to  sleep,  the  best  rest  is  change  of  work,  and 
that  change  of  work  in  its  turn  relieves  the  strain  of  worry 
and  anxiety,  and  mitigates  in  this  way  a  serious  danger  to 
mental  health.  There  is  no  greater  proof  of  the  mental 
strain  and  worr}^  of  present-day  life  than  the  simple  fact  that 
a  holiday  has  now  become  a  recognised  necessity  for  all 
classes,  and  that  for  men  engrossed  with  mental  work  a 
spring  holiday  is  required  to  supplement  the  autumn  holiday. 
Not  only  so,  but  outdoor  recreations  are  becoming  the  rule 
in  the  summer  months,  and  social  festivities  in  the  winter. 
Yet  it  miust  be  admitted  that  a  rational  system  of  holidays  is 
not  yet  understood  by  the  majority  of  the  people,  and  the 
more  medical  men  study  the  question,  the  better  will  they  be 
able  to  influence  the  mental  health  of  their  patients.  Re- 
cognising clearly  what  the  jaded  brain  requires,  the  medical 
man  will  be  able  to  map  out  the  kind  of  holiday  that  will 
best  suit  the  case.  An  aimless  holiday  devoted  to  killing 
time  is  just  a  new  kind  of  worr}-.  A  run  to  and  from  the 
coast  daily  increases  the  nervous  fatigue,  and  usually  leaves 
the  patient  worse  than  it  found  him.     A  long  sea-holiday  is 


32  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

often  exceedingly  beneficial  for  some  types  of  nervous  break- 
down. It  is  scarcely  possible  to  overdo  mental  exertion  on 
board  ship.  It  requires  an  effort  to  read  even  a  fascinating 
novel,  and  there  should  be  no  difficulty  in  the  patient  allow- 
ing himself  to  sink  into  a  delicious  state  of  mental  torpor 
almost  as  refreshing  as  sleep.  For  those  who  cannot  take  a 
sea-holiday  there  are  many  hobbies  which  can  give  abundant 
diversion  and  mental  rest.  There  are  the  delights  of  cycling, 
angling,  botanizing,  geologizing,  photography,  bowling, 
golfing,  tennis,  and  so  forth,  so  that  a  rational  holiday  can 
very  easily  be  arranged.  Speaking  of  social  attractions,  it  is 
well  to  bear  in  mind  that  some  are  hurtful,  and  really  do 
more  harm  than  good.  Excitement  must  be  discouraged. 
What  is  wanted  is  mental  change  without  exhausting  excite- 
ment. A  quiet  evening  from  home  is  to  the  average  man 
or  woman  much  more  helpful  than  the  excitement  of  the 
concert-room  or  ballroom,  and  you  must  carefully  guard 
against  allowing  patients  of  exquisite  musical  sensibility  to 
have  that  free  indulgence  of  their  favourite  passion  which  is 
apt  to  produce  intense  reaction  and  alarming  mental  de- 
pression. A  healthy  mind  requires  a  healthy  body,  and  the 
laws  which  regulate  the  health  of  the  body  must  be  strictly 
attended  to.  For  this  reason  each  individual  case  must  be 
studied  in  relation  to  physical  conditions,  and  particularly  so 
in  relation  to  their  effect  on  the  mind.  The  interdependence 
of  the  two  cannot  be  too  strongly  emphasized,  for,  strange  as 
it  may  seem  to  you,  they  are  often  regarded  in  practice  as 
separate  entities,  and  I  have  known  a  3^oung  medical  man 
treat  a  passing  mental  disturbance  by  severe  blistering  from 
the  nape  of  the  neck  to  the  sacrum,  when  all  that  was 
required  was  active  purgation  for  a  chronic  state  of  constipa- 
tion. 


CHAPTER  III. 

SLEEP.— INSOMNIA  AND  ITS  TREATMENT. 

Sleep  :  its  nature  and  the  conditions  necessary  for  it — The  cause  of  sleep  : 
various  theories-^Insomnia :  varieties  of  it  ;  incidental  and  morbid 
varieties — Causes  are  peripheral  or  central — Sometimes  leads  to 
insanity — Treatment  :  (a)  general,  (d)  special — The  former  includes 
daily  discipline,  and  attention  to  diet  and  drink — The  latter  includes 
rules  of  the  bedroom,  hydropathy  and  drugs. 

The  prime  restorer  of  exhausted  nature  is  sleep.  The  demands 
of  sleep  vary  with  the  individual,  and  are  determined  by  age, 
individuality,  manner  of  life,  and  occupation.  While  sleep 
is  essential  for  the  relief  of  bodily  fatigue  and  the  efficiency 
of  bodily  repair,  it  is  not  so  entirely,  for  horizontal  rest  can 
be  obtained  without  sleep,  and  pauses  of  this  kind,  with  the 
eyes  closed,  may  enable  man  to  do  without  it  for  a  long  time, 
provided  there  is  no  cerebral  demand.  This  demand  should 
be  attended  to  till  mental  rest  is  obtained  ;  for  while  bodily 
repair  can  be  effected  during  mental  exertion,  cerebral  repair 
can  only  be  effected  to  a  very  limited  extent,  and  then  is 
chiefly  confined  to  the  lower  and  reflex  centres.  A  certain 
amount  of  mental  rest  can  be  obtained  by  lying  down  and 
closing  the  eyes  and  ears  against  external  stimuli.  A  weary 
and  jaded  brain  may  rise  refreshed  from  a  pause  of  this  kind, 
and  do  a  good  night's  work ;  but  it  is  a  practice  that  is 
merely  useful  to  tide  over  a  special  crisis,  and  can  never  take 
the  place  of  natural  sleep. 

Ideal  sleep  is  absolutely  unconscious.  Experiments  on 
record  appear  to  prove  that  sleep  can  never  be  absolutely 
free  from  dreams.  Sir  William  Hamilton,  Exner,  and  others 
arranged  experiments  on   themselves  to  test  the  depth   of 

3 


34  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

mental  inactivity  during  sleep,  and  they  invariably  found 
themselves  at  the  moment  of  waking  occupied  with  the 
course  of  a  dream  {vide  Lyman,  p.  14).  These  experiments 
cannot  be  regarded  as  conclusive.  Just  as  the  actions  of  a 
whole  life  pass  in  review  in  a  moment,  as  when  drowning, 
dreams  flitting  from  pole  to  pole,  and  from  boyhood  to  man- 
hood, may  occur  in  a  very  brief  space  of  time,  excited  it  may 
be  by  the  mere  disturbance  of  being  wakened.  That  memory 
sleeps  soundly  is  probably  true,  for,  as  these  observers  point 
out,  we  rarely  remember  our  dreams.  It  is  well  known  that 
dreams  mostly  occur  m  the  morning  hours  before  waking, 
and  it  is  doubtless  true  that  sleep  is  most  profound  during 
the  first  hour,  and  that  the  tide  of  consciousness  returns 
slowly  after,  so  that  dreaming  is  not  only  probable  but 
physiological  before  the  hour  of  waking. 

Sleep  is  induced  by  fatigue,  and  the  sense  of  fatigue  indi- 
cates the  necessity  for  repose,  and  other  conditions  favourable 
to  sleep.  The  attitude  of  the  body  and  its  parts,  the  limp 
condition  of  the  muscular  system,  the  droop  of  the  head  and 
neck,  and  the  gravitation  to  a  horizontal  position,  indicate 
the  approach  of  sleep.  The  mind  becomes  sluggish,  the 
senses  less  acute,  and  a  state  midway  -  between  sleep  and 
consciousness  is  reached.  The  eyes  close,  and  reflex  move- 
ments are  for  the  moment  more  easily  excited,  induced  it 
may  be  by  weight  of  bedclothes,  uncomfortable  position,  or 
other  external  causes,  so  that  the  patient,  if  he  is  in  a  more 
nervous  state  than  usual,  or  if  he  is  naturally  nervous,  may 
be  wakened  by  slight  convulsive  movements  or  sounds  or 
visual  sensations  of  his  own,  that  are  merely  due  to  the 
suspension  of  higher  functions,  and  the  loss  of  inhibition  for 
the  time  being.  Soon  the  reflexes  and  sensory  excitements 
cease,  the  will  recedes,  and  the  intellectual  faculties  make 
their  exit  in  a  whirl  of  incoherence,  until  at  last  sleep  is 
supreme.  During  sleep  the  pace  of  all  the  functions  is 
reduced — respiration,  circulation,  etc. 

The  cause  of  sleep  has  been  discussed  for  ages,  and  many 
theories  have  been  advanced  on  the  subject.  Three  of  these 
may  here  be  referred  to  :  First,  that  sleep  is  due  to  venous 
congestion  is  an  opinion  founded  on  the  vascular  state  of  the 


SLEEP  35 

brain  in  comatose  states,  and  after  the  exhibition  of  opium. 
These,   however,   were    not    cases  of   natural    sleep,    and    it 
cannot  be  demonstrated  that  sleep  is  induced  by  congesting 
the  cerebral  circulation.     Second,  the  theory  of  anaemia  as  a 
cause  of  sleep  has  received  more  general  support,  and  of  late 
years  has  been  apparently  confirmed   by  experiments.     In 
i860   Durham  demonstrated,  by  trephining  experiments  on 
dogs,  that   the  supply  of  blood  to  the  brain  is  diminished 
during  sleep  ;  and  Mosso  of  Turin  observed  three  individuals 
who  had  suffered  from  defect  of  the  cranial  wall,  so  that  the 
cerebrum  was  exposed,  and  he  was  able  to  note  the  pulsation 
of  the  vessels  of  the  brain.     It  was  observed  {vide  Lyman, 
p.  26)  that  every  increase  of  emotional  or  intellectual  activity 
was  -attended  by  an  increase  in  the  cerebral  circulation,  and 
a  coincident  reduction  in  the  blood-supply  to  other  parts  of 
the  body.     The  occurrence  of  sleep  was  attended  by  a  reduc- 
tion of   the  volume  and    temperature  of  the    brain,   and   a 
coincident  dilatation  of  the  vessels  of  the  extremities.     More- 
over, if  a  ray  of  light  was  directed  on  the  eyelids,  or  if  any 
sense  organ  was  excited  without  awaking  the   patient,  the 
respiration  and  circulation  were  accelerated,  the  vessels  of 
the  extremities  contracted,  and  blood  flowed  more  freely  to 
the  brain.     It  is  worthy  of  note  also  that  in  anaemic  subjects 
there    is    often    a    lethargic    condition,   and    sleep    is    easily 
induced  ;  and  an  argument  in  favour  of  the  theory  of  anaemia 
as  the  cause  of  sleep  may  be  taken  from  the  fact  that  a  nap 
after  dinner  is  apparently  due  to  the  withdrawal  of  a  large 
volume  of  the  cerebral  circulation.     The  third  theory  is  that 
anemia  is  only  the  effect  of  a  sleep-producing  cause  ;  that  a 
nervous  impression  is  the  primary  event,  and  the  state  of  the 
circulation    a    consequence.      The    argument    for    the    third 
theory  is  this,  that  a  change  takes  place  in  the  nerve  cells, 
there   is  a   surcharge  of  waste  matter,  and  a  reduction  of 
energy,  so  that  there  is  not  only  suspended  function  from 
lack  of  energy,  but  also  from  obstruction  with  waste  matter ; 
there  is  no  call  for  the  vis  a  fronte  of  the  circulation,  and 
hence    the    anaemia   which    accompanies    sleep.     An    active 
tissue  calls  for  active  irrigation ;  hence  we  have  the  circula- 
tion in  the  brain  vigorous  and  full  in   response  to   mental 

•        3—2 


36  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

action,  feeble  and  depleted  as  a  consequence  of  mental 
inaction.  Sleep  is  really  induced  by  fatigue  of  nerve  cells, 
and  the  state  of  the  circulation  is  a  consequence  of  it ;  but 
just  as  the  jaded  horse  may  be  spurred  on,  so  the  jaded  cells 
may  be  stimulated  by  persistence  of  sensory  impressions  or 
mental  worry  and  excitement.  It  is  a  known  fact  in  physiology 
that  a  sensory  nerve  reduced  to  a  state  of  anaemia  has  its 
excitability  intensified  for  a  time,  and  the  same  rule  applies 
to  nervous  and  mental  actions  generally,  for  only  in  this  way 
can  we  explain  the  intensity  of  mental  excitement  which 
appears  in  a  feeble  physical  condition  in  states  of  anaemia 
and  nervous  exhaustion. 

The  necessary  duration  of  sleep  varies  with  the  individual. 
A  child  takes  more  than  a  man  in  proportion,  conversely,  as 
his  higher  faculties  are  not  evolved.  The  fewer  ideas  he  has, 
and  the  more  elementary  his  imaginative  faculty,  the  more 
reflex  is  his  mental  character,  so  that  when  his  senses  are 
satisfied  he  falls  asleep.  A  man  whose  work  is  muscular  and 
not  cerebral,  whose  mental  activity  is  almost  nil,  who  has 
no  mental  care  and  no  imagination,  goes  to  sleep  readily 
when  he  is  withdrawn  from  work,  and  has  satisfied  his 
appetites  and  other  organic  cravings.  The  man  who  does 
head  work  does  not  sleep  so  quickly,  especially  if  he  is  of  an 
anxious,  worrying  temperament,  if  his  imagination  is  too 
lively,  or  his  memory  too  obtrusive.  The  possibility  of  sleep 
depends  also  on  the  bodily  health,  particularly  on  the  digestive 
functions,  and  the  effect  of  meals  on  the  cerebral  circulation 
is  too  well  known  to  need  comment. 

Insomnia. 

Sleep  being  a  physiological  necessit}-  of  mental  health,  we 
naturally  turn  our  attention  to  the  consideration  of  insomnia 
or  sleeplessness,  which  must  exercise  a  serious  effect  on  the 
performance  of  mental  functions.  Insomnia  is  a  most  dis- 
tressing condition,  and  has  not  received  much  consideration 
in  general  practice  until  quite  lately.  Its  increasing  frequency 
in  our  experience,  and  its  relation  to  insanity,  are  sufficient 
reason  for  our  carefully  considering  its  causes  and  treatment. 


INSOMNIA  37 


There  was  a  time  when  opium  was  regarded  as  the  all-sufficient 
remedy.  If  a  glass  of  whisky-toddy  or  rum-punch  failed,  it 
was  drugged  with  opium  ;  but  the  indiscriminate  use  of 
opium  brought  its  own  cure,  and  a  reaction  against  its  use 
followed,  as  foolish  as  reactions  are  apt  to  be.  That  opium 
destroyed  digestion,  and  caused  a  craving,  was  undoubtedly 
true  ;  but  with  proper  precautions  it  may  still  be  regarded 
favourably  in  certain  cases.  Insomnia  is  variable  in  its 
symptoms  and  effects,  and  its  causes  are  numerous. 

One  great  distinction  may  here  be  drawn,  i.e.,  between 
peripheral  causation  and  cerebral  causation.  Peripheral 
causes  of  wakefulness  are  light  in  a  bedroom,  heat,  dis- 
agreeable smells,  noises,  remission  of  sounds,  as  from  noise 
to  silence,  and  movement  to  rest,  as  in  railway  travelling, 
irritating  cutaneous  diseases,  pain,  dyspepsia,  flatulence,  and 
other  visceral  disorders.  It  is  quite  correct  to  regard  wake- 
fulness or  disturbed  sleep,  induced  by  these  conditions,  as 
physiological,  for  no  healthy  brain  can  be  quite  indifferent 
to  them.  It  is  only  after  constant  repetition  that  sleepless- 
ness acquires  a  habit  and  becomes  morbid. 

The  important  causes  of  sleeplessness  3se  central,  and 
refer  to  the  action  of  the  brain  itself.  Heredity  undoubtedly 
operates  in  some  cases  more  than  others,  and  wakefulness  is 
often  a  family  symptom,  which  is  noticeable  in  families  of 
nervous  and  intellectual  types.  In  such  cases  it  is  not 
infrequently  associated  with  peripheral  conditions,  such  as 
dyspepsia  and  flatulence,  so  that,  except  under  the  influence 
of  hypnotic  treatment,  patients  of  this  class,  after  reaching 
maturity,  may  never  know  what  it  is  to  have  a  sound  sleep. 
Others,  again,  are  sleepless  because  of  mental  overstrain, 
the  mental  machinery  refusing  to  stop  when  work  is  done. 
Another  cause  is  excitement — political,  social,  intellectual, 
and  otherwise ;  indeed,  any  prolonged  and  intense  play  of 
emotion  is  sure  to  be  followed  by  insomnia. 

Next,  as  causes  of  sleeplessness,  come  worry  and  anxiety, 
remorse  and  passion.  It  must  also  depend  a  good  deal  on 
temperament,  and  it  is  well  to  discriminate  those  cases 
likely  to  suffer  in  this  way,  and  to  advise  them  accordingly. 
Of  course,  the  conditions  stated  imply  more  or  less  excite- 


38  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

ment,  and  therefore  a  condition  of  unrest,  if  not  a  positive 
frenzy   of  intellectual   faculties   and   emotions.     So  .long  as 
excitement    continues,   from  whatever   cause,   there   can    be 
no  sleep.     The  causes  of  excitement  are  so  various  that  I 
find  it  necessary  to   speak  in  a  general  way  of  the  subject. 
Two  old  friends  meet  after  a  long  severance,  perhaps  at  the 
end  of  a  long  railway  journey.     The}'  do  not  shake  hands  in 
the  perfunctor}-  way  of  an  everyday  greeting  ;   they  do  not 
speak  to  each  other  in  the  matter-of-fact  tone  of  a  passing 
salutation.     No.     There   is   a   distinct   rise   in   the   pulse  of 
feeling :    the   language  of  emotion   speaks   in  every  feature,- 
expression,  and  gesture  ;   the  sense  of  well-being  is  exalted, 
the    mind    is    excited,    memory    is    quickened,   reminiscence 
follows  reminiscence   in   quick  succession,   and   the  play  of 
emotion  and  intellectual  life  is  so  vivid  and  intense  that, 
when  they  look  at  the  clock,  and  see  how  long  they  have 
talked  into  the  night,  the  whole  thing  seems  a  dream.     Here 
there  is  an  intensity  of  consciousness,  emotion,  and  intellectual 
expression   wrought  to  such   a  pitch   that   when    they  seek 
repose    sleep    is    impossible.     The    mind    chews    its    cud  of 
reflection,   goes  over  the   evening  and    the   past  again   and, 
again,  rings  every  possible  change  on  the  imaginative-  and 
emotional   faculties,    and   speeds   from   thought   to   thought, 
memory  to  memory,  and  feeling  to   feeling,  with  a  whi-pkof 
feverish  delirium.     You  will  find  men  who  cannot  sleep-  if 
they  have  had  the  least  exciting  or  worrying  talk- just  before 
bedtime ;    others   who    cannot    sleep    if    they   read   in   the 
evening  ;  and  others — and  they  are  many — who  cannot  sleep 
if  they  study  late  at  night.     Lastly,  physical  fatigue  may  be 
too  acute  for  sleep  to  supervene. 

Insomnia  may  be  painful  and  acute,  the  mind  in  a  feverish 
delirium,  the  body  in  a  state  of  unrest.  There  is  a  nervous 
feeling  of  lightness  in  the  head,  of  something  wrong,  and 
often  a  feeling  of  depression  and  anxiety.  The  patient  may, 
and  often  does,  lapse  into  a  state  of  partial  unconsciousness 
in  which  he  may  be  said  consciously  to  dream,  and  in  which 
his  mind  is  the  sport  of  strange  fancies,  and  he  has  a  feeling 
that  he  is  not  the  same  person  as  when  awake  in  the  day- 
time.    He  is  uncertain  where  his  mind  will  lead  him,  and 


TREATMENT  OF  INSOMNIA  39 


feels  as  if  it  had  passed  from  his  control.  It  is  a  state  of 
most  distressing-  delirium,  which  can  often  be  put  a  stop  to 
by  getting  out  of  bed  and  reading  a  book,  or  in  some  other 
way  actively  diverting  the  mind.  But  there  is  a  condition 
of  wakefulness  sometimes  experienced  by  the  same  individual 
when  in  more  robust  health,  in  which  he  is  placid,  patient, 
expectant,  and  does  not  worry  for  sleep  to  come.  It  comes 
in  time,  and  although  he  may  have  passed  half  the  night  in 
a  wakeful  state,  it  has  been  attended  with  physical  rest, 
mental  quiet,  and  for  the  remaining  half  sleep  is  assured. 
In  some  cases  there  is  slowly  and  surely  going  on  a  process 
of  wear  and  tear  in  excess  of  the  repair  of  nervous  tissue  ;  the 
mind  is  strained,  the  emotions  are  accentuated,  and  there  is 
irritability,  impulsiveness,  and  want  of  judgment  and  staying 
power..  Finally,  by  the  operation  of  secondary  causes,  in- 
sanity may  be  induced.  Many  men  never  reach  this  ex- 
trem'ity'..  Wfeaikened  by  a  long  habit  of  imperfect  sleep,  the 
nervous .  system  reacting  on  the  general  system  induces 
susceptibilities  to  disease,  and  life  may  thus  be  shortened. 
Others, '  having  acquired  this  painful  habit,  arrange  their 
hours  and  work  to  suit  it,  and  by  careful  attention  to  physio- 
logical laws  live  on  doing  good  work,  though  in  moderate 
quantity,  and,  though  never  robust,  attaining  a  longer  age 
than  might  be  expected.  We  will  find,  then,  that  habitual 
insomnia  does  not  always  lead  to  insanity  ;  for  in  practice  it 
will  meet  us  at  every  turn,  and  we  may  be  able,  by  dis- 
criminating carefully,  to  treat  many  with  a  remarkable 
measure  of  success.. 

Treatment  of  Insomnia. 

The  treatment  of  insomnia  must  be  considered  under  two 
heads  :  (a)  General,  (b)  Special.  Under  general  I  include 
(i)  daily  disciphne ;  (2)  attention  to  diet  and  drinks.  Daily 
discipline  implies  a  good  deal.  It  requires  a  considerable 
exercise  of  self  -  denial,  and  it  must  rigidly  determine  the 
habits  and  manner  of  life  of  the  patient.  Whatever  treat- 
ment is  enjoined  under  the  second  head  must  here  be  in- 
sisted on.     Normal  sleep  comes  with  clockwork  regularity, 


40  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

but  it  presupposes  a  clockwork  regularity  of  daily  life,  and  a 
subordination  of  bodily  function  to  physiological  conditions 
— a  regular  routine  of  daily  life,  systematic  early  rising,  regu- 
larity of  meals,  work  mapped  out  so  as  not  unduly  to  fatigue, 
so  that  we  spring  back  from  it  easil}-  to  recreation,  and  a  fair 
allowance  of  exercise  at  times,  so  as  to  make  the  continuity 
of  mental  work  impossible.  Some  brain-workers,  leaving 
the  study  behind,  thinking  to  rest  their  brains,  go  into  the 
streets,  the  woods,  or  the  fields ;  it  is  all  one  which,  for 
objectively  they  are  blind,  and  the  brain  works  on,  thought 
on  thought  revolves  round  the  one  idea — i.e.,  the  subject 
which  was  not  left  behind  in  the  study.  Here  there  is  a 
want  of  discipline.  The  mind  has  acquired  the  habit  of 
never  giving  up  a  pursuit  until  it  is  finished,  and  while  auto- 
matically and  unconsciously  the  student  walks  the  streets, 
the  mind  is  still  busy  with  its  own  investigations.  Recrea- 
tion of  whatever  kind  must  be  genuine,  not  a  make-believe 
recreation.  It  must  leave  the  brain  better  than  it  found  it. 
It  must  refresh  after  toil,  and  therefore  it  must  have  a 
purpose,  and  draw  the  mind,  so  to  speak,  out  of  itself,  and  so 
relax  the  strain.  Daily  discipline  must  go  further.  Litera- 
ture of  an  exciting  kind  ought  not  to  be  indulged  in  at  all  if 
it  cannot  be  put  aside  at  will,  and  mental  occupation  of  an 
absorbing  or  intense  character  should  cease  for  some  hours 
before  bedtime.  Worry  and  anxiety  may  be  the  cause,  and 
in  such  cases  physical  occupation  is  the  best  preparation  for 
sleep  if  possible.  Self-discipline  must  also  be  exercised  in 
the  matter  of  diet  and  stimulants.  What  is  one  man's  meat 
is  another  man's  poison,  and  we  shall  see  by-and-by  that 
there  is  a  law  for  one  man  that  does  not  apply  to  another. 
I  have  spoken  of  bodily  diseases  as  causes  of  sleeplessness, 
and  particularly  of  dyspepsia  ;  and  when  the  subject  of  diet 
is  discussed,  this  will  be  again  referred  to.  What  I  have  to 
insist  on  now  is,  that  daily  discipline  in  the  matter  of  diet 
has  to  be  exercised  in  such  cases. 

The  general  treatment  of  insomnia  therefore  implies,  as  a 
fundamental  necessity,  daily  discipline  and  self-denial.  In 
the  next  place  it  implies  a  careful  consideration  of  diet  and 
stimulants.     The  diet  should  be  regulated  as  to  quality  and 


TREATMENT  OF  INSOMNIA  41 

quantity,  according  to  the  individual  case  ;  but  the  important 
point  to  remember  is,  that  the  digestive  tract  is  exceedingly 
sensitive,  and  when  excited  by  injudicious  dieting,  by  dis- 
order or  disease,  the  influence  on  the  brain  is  certain,  though 
the  patient  may  not  be  able  to  correlate  the  one  with  the 
other.  The  more  perfect  the  harmony  of  organic  sensation, 
the  more  favourable  the  condition  of  the  brain  for  repose. 
As  we  know,  stimulation  of  any  sense  organ  is  apt  to  waken 
a  patient  and  indeed  to  keep  him  from  sleeping  at  all. 
But  in  dyspepsia  and  flatulence  we  have  sensory  disturb- 
ances, scarcely  noticeable,  which*  are  very  apt  to  produce 
wakefulness.  The  vermiform  movements  of  the  intestines, 
eructations,  flatulent  distension,  and  other  conditions,  set  up 
sensory  disturbances  inimical  to  sleep,  so  that  restlessness, 
tossing  about,  without  any  sense  of  excitement,  merely 
wakefulness,  is  the  result.  For  such  cases  we  must  pay 
attention  to  diet.  Hence  also  the  old  adage,  '  After  supper 
walk  a  mile.'  We  have,  of  course,  heard  heavy  suppers  con- 
demned, but  '  no  supper  at  all '  should  be  equally  condemned. 
The  soothing  influence  of  a  glass  of  milk  and  a  biscuit  is 
remarkable.  Many  a  tossing,  restless,  feverish  state  has 
been  dispelled  by  this  simple  expedient. 

As  regards  stimulants  there  is  something  to  say  on  both 
sides.  They  are  certainly  safer  than  drugs,  but  are  they 
really  necessary  ?  In  some  cases  they  are.  In  the  treat- 
ment of  senile  cases  of  restlessness  and  sleeplessness  the 
exhibition  of  alcohol  in  moderate  doses  is  decidedly  bene- 
ficial. The  lack  of  elasticity,  of  nervous  energy,  and  re- 
cuperative power,  in  the  aged,  give  indications  for  stimulant 
treatment,  and  a  tumbler  of  toddy  at  bedtime  is  for  many  of 
them  a  desirable  hypnotic.  But  there  are  exceptions,  and 
we  must  distinguish  these.  Some  are  rendered  excitable 
and  wakeful  by  a  stimulant,  and  we  may  find  that  where  it 
has  been  a  habit  of  maturer  years  its  good  effects  in  senility 
are  less  manifest.  While  stimulants  may  be  indicated  in 
old  age,  it  is  not  so  clear  that  they  are  either  indicated  or 
desirable  in  early  or  mature  manhood.  I  would  not  say  that 
a  glass  of  grog,  a  tumbler  of  toddy,  or  a  pint  of  stout,  should 
be  pooh-poohed  in   all  cases.     Where  there  is  much  wear 


42  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

and  tear  of  nerve  tissue,  where  the  mind  will  not  rest  for 
worry  and  incessant  reflection,  where  to-morrow's  work  has 
to  be  done,  and  sleep  will  not  come,  especially  if  it  is  eagerly 
sought  for,  a  glass  of  grog,  aiid  even  a  second  dose  on  occasion, 
may  be  the  best  thing  possible.  But  I  would  give  warning 
against  prescribing  it  as  a  regular  habit,  especially  where 
there  is  a  bad  hereditary  history,  and  where  there  is  a  liking 
for  it.  Indeed,  where  there  is  a  bad  hereditary  history, 
everything  else  should  be  tried  rather  than  alcohol  or  hypnotic 
drugs.  In  prescribing  them,  care  should  be  taken  to  give 
what  suits  the  digestive  system.  Many  who  enjoy  a  good 
dinner  or  supper,  and  after  a  reasonable  pause  might  go  to 
bed  and  sleep  well  undisturbed  by  anything  they  have  eaten, 
may  remain  awake  for  hours  owing  to  indiscretion  in  drink- 
ing. Patients  subject  to  acid  dyspepsia  are  of  this  class, 
and  they  pay  for  such  indiscretions  as  drinking  hock,  claret, 
or  other  acid  wines  at  meals.  It  is  certainty  true  that 
alcohol  does  good  in  many  cases,  and  I  have  known  some 
where  it  has  relieved  many  a  mental  crisis  ;  but  in  all  such, 
cases  the  craving  was  absent,  and  it  was  taken  purely  as  a 
hypnotic.  It  is  certainly  to  be  preferred  to  the  habitual  use 
of  drugs,  and  the  dose  does  not  need  to  be  increased  in  any- 
thing like  the  same  ratio. 

Coming  now  to  special  means  of  treatment  for  the  cure 
of  insomnia,  I  will  speak  of  them  under  three  heads  :  {a)  Rules 
of  the  bedroom  :   (6)  Hydropathy  ;   (c)   Drugs. 

(a)  The  rules  of  the  bedroom  may  be  summarized  thus:, 
(^i-)  A  quiet,  retired  situation  ;  .(2)  thorough  ventilation  of  the 
bedroom  and  the  bedding  in  the  daytime  :  the  mattresses-,, 
pillows,  blankets,  and  everything,  about  a  bed  should,  be, 
freely  exposed  to  the  air  for  a  few  hours  everyday-;  (3)  the 
bed  should  be  well  made,  no,  hollows  or  inequalities  of 
resistance,  no  crumpling  of  the  sheets,  and  where  possible 
a  wire-wove  spring  mattress  :  feather  beds  are  objectionable  ; 
(4)  there  should  be  no  light,'  and  glaring  fires  should  be 
avoided.  If  light  is  necessary,  let  only  night-lights' be  used. 
The  tempeiavure  ot  the  room  should  be  moderate,  and  for 
otherwise  healthy  persons  a  fire  is  unnecessary. 

(6)   Hydropathy  is   now  a  favourite  remedy  for  many  ail- 


TREATMENT  OF  INSOMNIA  43 

ments  fancied  and  real ;  but  it  may,  and  often  will,  do  harm  , 
in  cases  of  insomnia  treated  by  injudicious  selection  of  baths,  j 
in  ignorance  of  their  physiological  effects.  The  favourite 
bath  for  sleeplessness  is  the  warm  bath,  but  it  is  frequently 
of  no  use.  That  a  warm  bath  has  a  soothing  effect  is  partly 
true  ;  but  that  it  is  usually  soporific  is  a  mistake,  though  I 
have  found  it  successful  in  some  nervous  cases.  It  may  be 
soporific  to  those  of  more  stable  temperament,  but  rarely  so 
to  a  man  or  woman  of  nervous  temperament,  and  these  are 
the  patients  most  likely  to  suffer  from  insomnia.  It  used  to 
be  thought  the  best  thing  possible  to  give  a  warm  bath  to  a 
nervous,  excited,  sleepless  patient,  but  I  have  seen  this  treat- 
ment produce  an  entirely  opposite,  effect.  A  man  once  so 
treated  passed  into  a  state  .of  frenzy^  and  suicidal  impulse 
from  which  he  never,  completely  recovered.  Neither  is  a 
warm  sitz  bath  anything  more  than  a  soothing  application 
for  the  time  being.  They  draw  the  blood  from  the  head,  we 
are  told.  Quite  so  ;  but  they  flush  it  back  in  fuller  volume 
when  the  period  of  reaction  sets  in.  The  use  of  the  cold 
bath  is  a  more  physiological  treatment  of  insomnia ;  but 
many  nervous  patients  feel  the  shock  too  much  :  their  circu- 
lation does  not  react  vigorously,  they  remain  cold  and  blue 
after  it,  and  vigorous  rubbing  fails  to  produce  a  sufficient 
glow  of  warmth  and  redness.  To  obviate  this  we  may  take 
the  chill  off  or  prescribe  a  cold  sitz  bath,  or  make  the 
patient  sit  in  a  chair  with  his  knees  and  feet  exposed  in  a 
large  foot-bath.  Then  pour  slowly  pailful  after  pailful  of 
ice-cold  water  over  the  knees  and  feet,  and  after  one  minute 
dry  and  rub  thoroughly.  Get  the  patient  back  to  bed,  and 
in  a  few  minutes  the  feet  begin  to  warm,  and  by-and-by  to 
get  decidedly  hot,  while  the  head  gets  cool.  The  effect  is 
precisely  the  opposite  of  a  warm  bath,  and  is  a  most  excel- 
lent expedient  in  some  cases.  Cold  applications  to  the 
head — a  towel  wrung  out  of  cold  water,  frequently  repeated, 
is  often  very  soothing  to  many  nervous  patients,  and  it  is 
sometimes  usefully  combined  with  a  warm  sitz  bath.  Mustard 
hip-baths  are  also  useful  in  cases  of  amenorrhoea  or 
dysmenorrhoea  with  excitement  and  wakefulness  ;  but  they 
must  not  be  prolonged,  or  the  irritation  produced  becomes 


44  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

excessive,  and  aggravates  the  state  of  the  patient.  It  is 
well  to  prescribe  the  use  of  a  bath  thermometer,  and  to  give 
precise  directions  as  to  the  temperature  required.  Individual 
cases  require  individual  treatment.  It  will  be  found  that  in 
some  a  tepid  bath  suits  best,  in  others  a  warm  bath  (95°), 
and  in  others  a  hot  bath  (110°) ;  but  the  question  is  one  for 
the  medical  attendant,  who  will  be  guided  by  the  nervous 
constitution  of  the  patient,  and  the  state  of  the  heart  and 
vascular  system.  The  time  spent  in  the  bath  must  also  be 
determined,  and  in  critical  cases  it  is  well  for  the  medical 
attendant  to  be  at  hand  for  carefully  observing  the  pulse  and 
general  condition  of  the  patient. 

(c)  The  treatment  by  drugs  resolves  itself  into  a  question 
of  direct  and  indirect  treatment.  Indirect  treatment  is  that 
prescribed  because  of  secondary  effects,  e.g.,  for  bodily  con- 
ditions inimical  to  sleep,  such  as  dyspepsia,  neuralgia, 
rheumatism,  etc. 

Direct  treatment  is  prescribed  for  direct  effects,  i.  Opium 
is  a  certain  hypnotic ;  but  it  is  one  not  to  be  trifled  with, 
and  medical  men  incur  responsibility  in  prescribing  it, 
though  in  a  lesser  degree  this  may  also  be  said  of  prescrib- 
ing any  hypnotic.  It  disturbs  secretory  and  digestive 
functions  where  pushed  indiscriminately.  Given  in  moderate 
doses,  it  quickens  mental  activity,  unless  the  patient  dis- 
courages thought  and  allows  himself  to  fall  into  a  passive 
state  which  paves  the  way  for  its  soporific  action.  Where 
sleeplessness  is  due  to  pain  or  peripheral  irritation,  as,  for 
example,  in  puerperal  conditions,  it  is  most  useful,  and  may 
be  prescribed  in  the  form  of  Tr.  Opii  or  Morphia  Supposi- 
tories, the  dose  being  determined  by  the  intensity  of  the 
symptoms.  It  is  well  not  to  give  a  full  dose  to  begin  with, 
but  rather  to  repeat  cautiously  until  the  desired  effect  is 
obtained,  and  it  is  well  also  not  to  err  on  the  side  of  over- 
caution,  for  then  the  last  state  of  the  patient  is  worse  than 
the  first. 

2.  C Moral  is  also  a  certain  hypnotic,  but  here  also  great 
care  requires  to  be  exercised,  especially  in  weakness  of  the 
heart,  respiratory  disease,  and  disease  of  the  bloodvessels. 
It    may    produce    headache,    drowsiness,    sickness,    loss    of 


TREATMENT  OF  INSOMNIA  45 

appetite,  and  disorder  of  the  liver,  but  it  is  safer  than  opium. 
It  is  best  to  give  it  with  bromide  of  potassium. 

3.  Bromide  of  potassium  is  a  very  safe  hypnotic  ;  it  rarely 
disturbs  the  digestive  and  hepatic  functions,  but  given  alone 
it  is  physically  depressing  if  continued  for  a  long  time,  as  the 
dose  requires  to  be  increased.  When  sleeplessness  is  acute, 
and  accompanied  by  excitement,  a  combination  of  bromide 
of  potassium  with  chloral — 25  grains  of  the  former,  and  15  to 
20  grains  of  the  latter — is  a  much  more  effective  hypnotic. 

4.  Paraldehyde. — This,  but  for  its  offensive  taste  and  smell, 
would  be  a  favourite  hypnotic,  and  it  is  especially  indicated 
where  cardiac  or  general  weakness  contra-indicate  the  exhibi- 
tion of  depressing  remedies.  It  is  best  administered  in  drachm 
doses  with  Tr.  Aurantii,  which  helps  to  mask  its  most  un- 
pleasant taste  and  smell. 

5.  Sulphonal. — This  drug  has  been  much  in  favour  for  a 
time,  but  after  the  novelty  of  its  use  wore  off,  it  fell  rather 
into  disrepute.  The  chief  reasons  assigned  for  this  were  its 
insolubility,  its  irritant  effects  on  the  gastro-intestinal  tract, 
and  the  occasional  occurrence  of  hgemato-porphyrinuria  after 
its  use.  I  have  still  faith  in  sulphonal,  and  if  caution  is 
manifested  in  its  use,  it  will  be  found  both  safe  and  reliable. 
As  it  does  not  dissolve  well,  its  action  is  necessarily  slow,  and 
especially  so  in  gastric  disorders.  It  is  best  given  after  mixing 
with  boiling  milk,  which  is  afterwards  allowed  to  cool  a  little, 
or  it  may  be  given  in  alcohol.  The  dose  is  i5"to  40  grains, 
but  it  may  be  administered  in  two  moderate  doses,  with  an 
interval  of  three  hours  between.  The  urine  should  be 
examined  frequently,  and  the  faintest  tinge  of  red,  or  a 
darkening  of  its  colour,  should  be  taken  as  a  warning  to  stop 
the  medicine.  Its  use  is  contra-indicated  in  adrenal  or  renal 
disease.  In  this  connection  reference  may  be  made  to  the 
following  observations  of  B.  J.  Stokvis,  M.D.  : 

'  In  respect  to  sulphonal  as  a  cause  of  hgemato-porphy- 
rinuria, the  occurrence  of  large  quantities  of  heemato-porphyrin 
in  the  urine,  and  of  haemorrhage  in  the  alimentary  canal,  can 
be  wholly  checked  in  animals  (rabbits)  by  involving  the 
irritant  substance  in  demulcent  liquids,  as  milk,  solution  of 
starch,  etc' — Journal  of  Pathology  and  Bacteriology,  July,  1896. 


46  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

6.  Hypodermic  Treatment. — Morphia,  hyoscyamine,hyoscine, 
have  been  tried.  In  ordinary  practice,  as  in  relieving  pain 
in  order  to  procure  sleep,  a  hypodermic  injection  of  morphia 
is  an  excellent  expedient,  but  the  injection  must  be  given  by 
the  doctor  hifRself.  In  the  treatment  of  acute  mental  excite- 
ment, the  hydrobromate  of  hyoscine  (yi-o  to  -gL  of  a  grain)  is 
prompt  and  reliable.  If  there  is  cardiac  or  vascular  disease, 
it  requires  to  be  given  with  caution,  but  I  have  had  no  bad 
results  in  such  cases.  It  is  well  to  begin  with  smaller  doses 
at  first,  as  the  susceptibility  of  patients  varies. 

Indirect  Treatment. 

7.  Liquor  Amman.  Acetatis. — In  cases  of  mild  sleepless- 
ness, where  excitement  is  not  distressing,  and  a  placid  state 
of  mind  is  the  rule,  this  medicine,  by  increasing  the  vascu- 
larit}'  of  the  skin,  relieves  the  brain,  and  promotes  a  natural, 
refreshing  sleep.  It  is  therefore  not  narcotic,  and,  being  a 
febrifuge  frequently  prescribed  for  children,  it  may  be  re- 
garded as  the  safest  of  all  hypnotics.  In  private  practice  I 
have  found  it  very  useful  in  doses  of  half  an  ounce  or  more, 
repeated  if  necessary. 

It  is  not  necessary  to  dwell  at  greater  length  on  the  subject 
of  indirect  treatment.r.  Where  there  is  bodily  disease  or 
disorder,  a  cause  of  insomnia  frequently  exists  until  sensory 
relief  is  obtained,  and  distressing  symptoms  must  in  all  such 
cases  be  relieved  or  minimized  to  allow  exhausted  nature  a 
chance  of  repose. 


CHAPTER  IV. 

THE  EXAMINATION  OF  MENTAL  CASES.— DIAGNOSTIC 
CHARACTERS  OF  INSANITY. 

Method  of  mental  examination — Is  there  a  standard  of  sanity  ? — Generic 
symptoms  of  insanity  which  may  be  regarded  as  diagnostic  characters 
— Illusions,  hallucinations,  delusions,  and  their  varieties — Distinction 
of  these  three  mental  states — The  states  of  depression,  exaltation,  and 
enfeebiement — Disordered  emotions  and  instincts — Excitement,  in- 
coherence, suicidal  and  homicidal  impulses — Obsession,  Aboulia, 
Verbigeration. 

Mens  sana  in  corpore  sano  is  the  ideal  of  health,  but  in  actual 
practice  we  sometimes  neglect  to  couple  these  two  ideas, 
being  carried  away  by  the  urgency  of  the  mental  symptoms, 
and  disregarding  the  physical  state  altogether.  The  clinical 
conception  must  take  in  the  whole  man  mentally  and  ph3'si- 
cally.  Is  there  a  mental  standard  of  sanity  ?  This  is  a 
question  which  arrests  a  medical  man  when  he  is  called  on  for 
the  first  time  to  testify  as  to  the  mental  capacity  of  anyone. 
A  brief  consideration  of  what  has  been  already  said  in  pre- 
ceding chapters  should  satisfy  us  that  beyond  general  data 
there  is  no  standard.  The  individual  in  question  must 
possess  mental  faculties,  but  his  character  may  differ  from 
another's  as  widely  as  possible,  and  yet  not  transgress  the 
bounds  of  sanity.     Every  sane  man  is  his  own  standard. 

A  systematic  examination  of  a  man's  mental  state  should 
be  undertaken  in  the  following  order  : 

First:  Inquire  as  to  sensation,  perception,  language, 
memory,  emotions,  will  and  impulses,  moral  nature,  and 
so  forth  {vide  Chapter  I.).  There  may  be  congenital  deficiency, 
which  if  extreme  m.arks  him  an  idiot  or  an  imbecile.  There 
may  be  deficiency  as  the  result  of  disease  or  accident,  but  it 


48  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

may  not  be  enough  to  signify  insanity.  If  it  does,  we  call  it 
acquired  insanity. 

Second  :  Inquire  next  whether  his  mental  character  is 
altered  beyond  its  legitimate  range  [vide  Chapter  IL),  and 
remembering  that  character  is  differently  manifested  at 
different  epochs  of  life,  and  in  accordance  with  certain 
laws,  we  must  determine  whether  the  character  in  ques- 
tion is  consistent  with  such  laws  of  variation. 

In  coming  to  a  decision,  remember  that  we  are  not 
guided  thereto  by  any  definition  of  insanity.  There  is  no 
accepted  definition  of  insanity  in  medical  jurisprudence  or 
elsewhere.  No  satisfactory  definition  has  yet  been  con- 
ceived, and  in  actual  practice  medical  men  get  along  very 
well  without  it. 

In  medical  practice  many  patients  are  treated  for  mental 
symptoms,  and  for  obvious  reasons  no  name  is  attached  to 
the  case.  If  it  can  be  called  neurasthenia  (nervous  exhaus- 
tion) or  hvsteria,  the  patients'  friends  are  grateful,  and  the 
medical  man  is  only  too  glad  to  meet  their  wishes  if  he  can. 
When  active  measures  have  to  be  taken,  or  when  the  case 
has  to  be  regarded  in  a  medico-legal  aspect,  there  is  a  new 
view  of  the  matter  altogether.  The  course  is  clear  :  technical 
insanity  must  be  recognised. 

Insanitv  is  therefore  a  term  of  considerable  elasticity.  It 
has  many  symptoms,  and  some  so  generic  that  they  may  be 
regarded  as  diagnostic  characters.  These,  as  a  fitting  intro- 
duction to  the  systematic  study  of  insanity,  may  now  be 
appropriately  considered  here. 

The  inflexions  of  a  language — the  genders,  cases,  moods, 
and  tenses — are  not  more  numerous  and  varied  than  the 
symptoms  of  mental  disease.  They  cannot  all  be  put  on 
paper,  nor  is  it  necessary  to  do  more  than  arrange  them  under 
their  natural  orders.  Bearing  in  mind  what  are  the  founda- 
tions of  a  mental  constitution,  it  is  interesting  to  observe 
that  sensation  is  often  at  fault  in  mental  disease.  That  manj^ 
errors  of  sensation  are  common  in  ever^'day  life,  and  by  no 
means  related  to  mental  disease,  is  perfectly  true ;  but  on 
the  threshold  of  the  mental  activities,  where  sensation  com- 
municates with  mind,  errors  of  graver  import  are  also  common. 


ILLUSIONS  49 


though  they  do  not  in  many  cases  betoken  insanity.  Two 
grave  errors  referred  to  sensation  stand  out  conspicuous, 
viz.,  illusion  and  hallucination. 

Illusion  means  a  false  perception  by  any  of  the  senses  of 
an  object  or  stimulus.  The  word  stimulus  is  here  coupled 
with  object,  so  as  to  make  the  definition  complete ;  for  it 
seems  out  of  place  to  talk  of  sound  waves  and  the  molecular 
irritants  of  the  end  organs  of  taste  and  smell  as  being  objects 
in  the  sense  that  an  object  in  the  field  of  vision  is  so  regarded. 
The  point  of  importance  is  that  in  the  case  of  illusion  an 
object,  or  call  it  a  stimulus  if  you  please,  impinges  by  rays, 
waves,  or  molecular  apposition  on  the  end  organ  of  vision, 
hearing,  or  other  sense,  and  there  is  an  error  in  the  sense 
perception  of  its  true  character.  In  the  case  of  a  halluci- 
nation there  is  no  peripheral  stimulus  ;  the  error  of  sense 
perception  is  in  the  function  of  the  sensory  tract,  or  purely 
inental. 

Many  illustrations  of  illusions  may  be  cited  from  general 
experience,  as  they  are  really  common  in  the  life  of  the 
sane.  Illusions  are  excited  by  the  use  of  intoxicants,  such 
as  alcohol,  cannabis  indica,  and  hallucinations  are  still  more 
likely  to  arise  under  the  influence  of  such  agents.  The 
examples  of  illusions  might  be  quoted  profusely ;  but  it  is 
enough  to  say  that  objects  may  appear  larger  than  their 
natural  size,  or  the  men  and  women  around  may  look  like 
midgets  ;  in  defective  light  ghostly  apparitions,  or  grotesque 
exaggerations  of  size  and  shape,  may  appear  ;  but  an  appeal 
to  reason  is  enough  to  dispel  the  illusion.  An  illusion  is 
regarded  as  insane  when  an  appeal  to  reason,  aided  perhaps 
by  the  remaining  senses,  does  not  dispel  the  illusion  ;  but  if 
this  strictly  applied  in  practice,  our  ancestors  who  believed 
in  ghosts  must  have  been  insane.  Here,  as  in  every  law  of 
life,  we  find  rules  with  exceptions.  An  example  of  an 
insane  illusion  is  where  a  woman  calls  a  cat  a  baby,  or 
says  that  the  pillow  is  her  child. 

Optical  effects  are  often  very  puzzling,  and  make  the 
observer  doubt  his  own  senses  until  the  cause  is  explained. 
The  same  holds  true  of  strange  sounds,  especially  in  the 
night-time,  when  one  is  awake  and  nervous,  and  the  sense 

4 


50  CLINICAL  MANUAL  OF  MENTAL  DISEASES 


of  hearing  is  on  the  alert.  It  is  probably  by  gradations  from 
the  real  to  the  unreal  that  the  hallucinations  of  subacute 
alcoholic  insanity  develop  themselves. 

Hallucination  is  a  false  sense  perception  without  a  stimulus 
applied  to  the  end  organ  of  any  of  the  senses.  When  a  man 
says  that  he  sees  a  woman  galloping  on  horseback  over  the 
sea,  or  that  by  placing  his  ear  against  a  wall  he  hears  the 
voice  of  his  mother,  who  has  been  dead  for  thirty  years,  we 
sa}'  that  he  has  in  the  first  instance  a  hallucination  of  sight, 
and  in  the  second  a  hallucination  of  hearing.  It  is  some- 
times difficult  to  distinguish  between  illusion  and  hallucina- 
tion, for  there  may  be  a  doubt  whether  or  not  the  end  organ 
of  anv  sense  is  being  stimulated.  Hallucinations  of  hearing 
have  been  noticed  to  be  very  active  in  an  assembly  where 
there  is  a  subdued  hum  of  voices,  and  again  they  are  noticed, 
to  use  a  familiar  phrase,  '  in  the  stillness  of  the  night,'  or 
'  where  you  could  hear  a  pin  fall.'  It  may  be  that  the 
absolute  silence,  by  withholding  sense  stimuli,  may  accentuate 
the  morbid  stimulation  within  the  brain  of  one  individual, 
and  that  the  subdued  hum  may  have  a  positive  effect  on 
cases  of  the  same  or  of  another  kind  altogether. 

You  will  find  in  practice  that  there  are  doubtful  cases,  and 
you  will  be  at  a  loss  to  distinguish  between  illusion  and 
hallucination.  In  any  doubtful  instance,  if  there  is  evidence 
of  insanity,  and  the  insane  idea  is  not  of  visceral  or  hypo- 
chondriacal character,  you  have  probabh'  a  hallucination,  or 
perhaps  a  delusion,  for  these  symptoms  are  much  more 
common  among  the  insane  than  illusions.  Hallucinations 
mav  affect  any  of  the  senses ;  but  whether  they  are  due  to 
mere  errors  of  sense  perception,  or  have  a  mental  explana- 
tion, is  still  a  matter  of  conjecture.  The  following  are 
examples  : 

(a)  Hearing,  (i)  Hears  her  children  calling  to  her  from 
under  the  floor  ;  (2)  hears  voices  from  the  ceiling  calling  her 
names ;  (3)  hears  voices  of  her  enemies  in  the  right  side  of 
her  head,  and  strikes  that  side  with  great  fury.  Says  the 
left  side  of  her  head  is  where  the  society  women  are,  and 
there  her  friends  reside  :    they  seldom  speak  to  or  annoy  her. 

[b)  Sight.     (I)  Sees  her  children  in  the  fields,  and  points 


HALLUCINATIONS  51 

to   men   stabbing  them  with    knives ;    (2)   sees    visions   and 
witches  burning. 

(c)  Taste  or  Smell.  Example :  says  her  food  smells  of  sulphur, 
and  has  a  very  offensive  taste.  There  is  difficulty  here  in 
distinguishing  between  illusion  and  hallucination. 

It  is  important  to  discriminate  between  hallucination  and 
delusion,  or,  it  may  be,  what  is  merely  a  figure  of  speech. 
The  mere  fact  that  a  man  says  that  he  hears  God's  voice  in 
a  storm  is  not  necessarily  evidence  of  a  hallucination,  for 
many  perfervid  religious  people  use  such  exalted  expressions 
to  signify  their  nearness  in  sentiment  and  imagination  with 
the  Almighty. 

Hallucinations  are  not  always  of  equal  intensity,  nor,  as 
in  the  case  of  hearing,  for  example,  are  they  always  bilateral. 
I  remember  one  case  of  puerperal  delirium  in  which  the 
patient  heard  at  one  moment  the  sounds  of  paddle-wheels 
in  one  ear  (her  husband  was  captain  of  a  paddle-steamer), 
and  anon  the  sound  of  bagpipe  music  in  the  other  (she  was 
of  Celtic  origin).  Though  perhaps  less  common  among  the 
sane  than  illusions,  they  are  b}-  no  means  uncommon,  and 
when  the  mind  is  overwrought,  and  the  senses  hypersensitive, 
they  are  particularly  noticeable  when  in  bed,  and  often  just 
when  dropping  off  to  sleep  (hypnagogic).  Dr.  Ireland,  in 
his  most  interesting  book,  '  The  Blot  on  the  Brain,'  gives 
several  instances  of  sane  hallucinations.  He  quotes  from 
the  British  Medical  Journal  of  March  10,  1883,  the  case  of 
an  elderly  lady  in  the  full  possession  of  her  mental  faculties 
who  had  cataract  forming  in  both  eyes,  and  who  saw  nearly 
every  day  for  some  time  a  church  with  numbers  of  people 
entering  it,  and  carriages  driving  up ;  or  an  alternative  scene 
of  a  market-place  full  of  life,  opposite  her  windows.  She 
was  quite  aware  that  there  was  nothing  of  the  kind  in  reality, 
and  when  she  shut  her  eyes  the  scene  vanished.  Some 
hallucinations  of  sight  appear  only  when  the  eyes  are  shut, 
while  others  are  produced  only  in  the  dark.  Hallucinations 
may  affect  any  of  the  senses  :  those  of  sight  and  hearing  are 
most  common. 

Delusions. — An  insane  delusion  may  be  defined  as  a  false 
belief,  the  result  of  diseased  mental  action.     There  are  delu- 

y.  (. '         '  ■ 


52  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

sions  familiar  to  us  every  day,  delusions  to  which  we  are  all 
subject,  false  beliefs,  mistaken  judgments,  which  cannot  be 
described  as  insane.  We  would  never  think  of  ascribing 
insanity  to  the  victims  of  popular  delusions  and  supersti- 
tions, which  are  largeh'  dependent  on  ignorance  ;  but  an 
insane  delusion  is  a  false  belief  founded  on  diseased  mental 
action,  and  of  such  the  name  is  legion.  Thus,  when  a  man 
believes  himself  to  be  a  king,  or  that  he  is  a  teapot,  or  that 
he  is  made  of  glass,  or  that  he  is  worth  millions  of  money, 
when  in  point  of  fact  he  is  not  worth  a  sixpence,  the  insanity 
of  his  delusion  is  so  self-evident  that  for  him  to  argue  the 
matter  is  obviously  absurd.  Delusions  have  been  differenth' 
classed  according  to  their  type,  or  the  particular  mental 
faculty  more  prominently  involved. 

Delusions,  like  hallucinations,  ma}'  be  more  apparent  than 
real.  They  may  be  feigned ;  they  may  be  merely  the  out- 
come of  a  desire  of  vainglory,  or  entirely  due  to  suggestion. 
One  old  lady,  a  chronic  case  of  puerperal  insanity,  is  utterly 
inconsistent  in  her  statements  day  after  day ;  the  only  per- 
sistent delusions  are  certain  delusions  of  identity  and  persecu- 
tion and  her  being  the  mother  of  God.  She  will  tell  you  in 
the  morning  that  she  was  in  heaven  last  night,  that  she  was 
out  fishing  at  the  same  time  with  Jesus  Christ,  and  that  in 
her  bed  last  night  she  was  assaulted  by  a  man  named  Tait, 
who  had  poisoned  her  before  morning.  Here  there  are  only 
two  fixed  ideas,  the  relationship  of  Jesus  Christ  and  the 
wickedness  of  Tait ;  but  she  paints  fresh  pictures  every 
morning,  and  contradicts  her  statements  of  the  previous 
day,  all,  however,  having  for  their  central  figures  Jesus  Christ, 
her  son,  and  Tait  the  persecutor.  The  fact  is  that  she  colours 
her  delusions  and  romances  wildly  and  extravagantly  to  satisfy 
her  insane  egotism  and  vanity. 

Apparent  delusions,  that  are  apt  to  be  taken  serioush',  and 
which  ought  not  to  be  regarded  so,  are  man}'  of  the  so  called 
exalted  delusions  of  the  general  paralytic.  To  understand 
his  delusions,  real  and  unreal,  it  must  be  remembered  that 
the  mainspring  of  his  extravagances  is  his  state  of  feeling. 
It  is  exalted ;  he  feels  extravagantly  great  and  strong ;  his 
personal  equation  is  immense,  and  this  state  of  feeling  excites 


DELUSIONS  53 

ideas  of  greatness,  strength,  and  unlimited  resource.  Un- 
doubtedly, when  these  ideas  are  entertained  without  restraint, 
he  gives  them  speech,  and  proclaims  himself  a  mighty 
monarch,  a  millionaire,  and  so  forth.  With  the  ebb  and 
flow  of  feeling  these  great  ideas  recede  and  return  again,  but 
there  are  large  ideas  which  may  not  occur  to  him,  and  which 
he  will  adopt  as  true  on  your  suggestion.  Ask  him  if  he  can 
run  a  locomotive  at  150  miles  an  hour  :  his  sense  of  power 
will  not  allow  him  to  say  no,  but  until  you  suggested  the  idea 
it  was  never  there,  and  you  can  thus  manufacture  unlimited 
so-called  delusions  by  mere  suggestion  if  his  sense  of  power 
or  well-being  happens  to  be  exaggerated  at  the  moment. 
That  many  so-called  delusions  are  fictitious  is  beyond  a 
doubt,  and  the  same  can  be  said  of  hallucinations. 

In  order  to  focus  the  distinction  between  illusion,  hallucina- 
tion, and  delusion,  let  me  state  the  following  case  :  An  old 
woman  says  that  two  dolls  are  her  children,  and  that  they 
asked  her  to  give  them  food.  Suppose  the  dolls  to  be 
mechanical  dolls,  that  were  made  to  emit  a  sound,  we  have 
one  of  the  conditions  of  illusion — an  external  stimulus;  and  if 
she,  by  a  false  sense  perception,  transmuted  this  sound  into 
words,  we  have  the  other  condition — a  false  sense  perception, 
and  therefore  an  illusion. 

When  a  real  baby  cries,  and  its  mother  suckles  it  in 
response  to  the  cry,  she  understands  that  it  wants  food,  but 
she  does  not  say  that  the  child  asked  in  words  for  food. 
The  old  woman  may  only  be  insane  to  the  extent  that  she 
believes  the  dolls  to  be  real  children,  the  mechanical  cry  a 
real  cry  ;  and  admitting  so  much,  it  may  be  only  an  infer- 
ence that  the  children  want  food.  We  see,  therefore,  a  diffi- 
culty in  discriminating  the  true  from  the  false,  and  we  shall 
now  see  how  an  apparent  illusion  may  be  the  result  of 
hallucinations. 

To  say  that  the  dolls  are  her  children  is  possibly  an 
illusion,  for  there  is  here  an  object,  and  possibly  a  false 
perception ;  but  we  must  make  perfectly  sure,  for  possibility 
does  not  make  it  a  certainty.  The  solution  came  a  few  days 
later,  when  the  old  woman  expressed  herself  somewhat 
differently,  thus  :   '  She  said  she  saw  the  spirit  of  her  aunt 


54  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

(hallucination  of  sight),  which  told  her  that  the  dolls  are  her 
two  children  (hallucination  of  hearing).'  The  first  half  of  the 
first  statement  therefore  does  not  reveal  illusion,  but  is  the 
result  of  hallucination. 

Examine  now  this  further  statement.  The  old  woman, 
having  mislaid  her  children  (dolls),  declares  that  they  have 
been  stolen,  for  she  saw  a  nurse  carrying  a  bundle  (a  parcel 
of  clothing)  away.  She  regards  the  nurse  as  a  woman  who 
has  designs  on  her  life.  There  is  no  question  here  of  an 
error  of  sensation.  She  has  the  delusion  that  they  are 
stolen,  and  also  the  delusion  that  the  nurse  has  designs  on 
her  life. 

Sensations  (cephalic  or  otherwise) — obscure,  unpleasant 
sensations — are  probably  the  exciting  cause  of  many  delu- 
sions, and  the  difficulty  of  distinguishing  between  delusion, 
hallucination,  and  illusion  in  such  cases  is  often  considerable. 

Delusions  are  frequently  started  from  the  emotional  centre 
of  the  mind,  and  it  is  safe  to  say  of  most  delusions  gradually 
evolved — not  those  suddenly  sprung  on  the  mind,  as  in  acute 
cases  of  insanity — that  their  origin  is  traceable  either  to 
doubt,  fear,  suspicion,  or  a  feeling  of  well-being.  This  is 
true  also  of  many  delusions  of  the  acute  mental  states,  but 
these  are  often  the  result  of  an  insane  association  of  ideas 
immediately  suggested  at  the  moment.  To  trace  the  origin 
of  delusions  to  their  source,  sane  or  insane,  is  a  very  interest- 
ing, though  sometimes  a  very  difficult,  study,  but  it  is 
beyond  our  present  purpose  to  consider  this  further.  The 
following  case  may  be  quoted  to  illustrate  what  might  or 
might  not  be  a  delusion  : 

James  R.  is  very  deaf  in  the  right  ear.  He  has  been 
treated  with  intra-aural  injections,  via  the  Eustachian  tube, 
by  a  doctor  in  a  general  hospital.  In  after-years  he  described 
it  thus  :  '  They  pumped  medicine  up  into  my  brain,  and  it 
came  out  by  my  mouth.'  This  man  is  illiterate,  and  his 
statement  by  itself  is  no  evidence  of  insanity,  but  of  ignor- 
ance. Observe,  however,  that  he  made  the  statement  with 
an  angry  look  on  his  face,  an  expression  of  suspicion  and 
distrust.  Then  delusion  is  suspected,  and  when  we  inquire 
further,  and  find  that  he  believes  he  has  enemies  who  plot 


VARIETIES  OF  DELUSION  55. 


against  his  life,  though  he  can  give  no  sane  proof  of  this,  the 
first  statement  becomes  evidentl}'  a  delusion. 

We  may  now  profitably  consider  different  kinds  of 
delusions. 

(a)  Depressing  delusions  are  frequently  of  a  religious 
character,  as  when  a  man  declares  that  his  soul  is  lost 
because  he  has  committed  the  unpardonable  sin.  It  may  be 
argued  by  some  that  no  one  can  prove  otherwise  in  this  case, 
and  that  it  may  not  be  a  delusion.  When  he  states  that  he 
is  to  be  offered  up  a  sacrifice  for  the  sins  of  his  family,  or 
that  his  being  put  into  the  asylum  is  a  judgment  from  God 
for  going  to  sleep  in  church,  we  have  evidence  of  depressing 
delusions.  There  are  many  depressing  delusions  of  a  non- 
religious  type  ;  for  example,  when  a  man  says  he  is  to  be 
put  in  prison  for  debt,  when  a  woman  says  her  children  have 
been  kidnapped. 

{b)  Hypochondriacal  delusions  might  be  written  down  as 
an  offshoot  of  the  class  of  depressing  delusions,  but  so  also 
might  several  other  forms.  Most  delusions  may  be  described 
as  having  particular  characters  (example  :  hypochondriacal, 
grandiose),  and  having  particular  effects  (example  :  depress- 
ing, exalting).  Hypochondriacal  delusions  are  of  necessity  a 
result  of  morbid  self-interest  and  introspection.  The  hypo- 
chondriac is  continually  taking  stock  of  his  feelings  and 
sensations.  He  has  usually  some  favourite  organ  or  system 
which  claims  his  undivided  attention.  It  may  be  his  liver, 
but  more  frequently  it  is  his  bowels.  Sometimes  it  is  his 
heart ;  more  frequently  it  is  his  head  and  its  multitude  of 
strange  sensations.  Whatever  it  is,  always  remember  that 
there  may  be  a  substratum  of  truth  in  his  statements,  and  do 
not  treat  such  cases  too  cavalierly.  Because  a  man  mopes 
and  broods  over  the  supposed  loss  of  his  stomach,  the  gas  in 
his  head,  or  the  closure  in  his  throat,  you  must  not  assume 
that  this  is  a  mere  abstract  imagination.  It  may  be  founded 
on  fact,  and  for  the  sake  of  the  patient  and  your  own  peace 
of  mind  after,  it  is  very  desirable  that  you  should  make  a 
careful  clinical  examination  of  the  region  referred  to. 

(c)  Exalted  delusions,  such  as  when  a  man  says  that  he  can 
build  a  man-of-war  in  three  days,  that  he  is  Jesus  Christ, 


56  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

that  he  has  invented  a  machine  to  destroy  the  world,  that 
he  is  King  of  the  Cannibal  Islands,  or  that  he  is  Jupiter. 
Under  this  head  may  be  mentioned  delusions  denoting  pride 
and  grandeur. 

(d)  Delusions  of  suspicion,  as  when  a  man  is  morbidly 
suspicious,  misinterprets  the  words,  actions,  and  gestures 
of  those  around  him,  regards  everything  said  and  done  as 
having  reference  to  himself;  or  more  pronounced  delusions, 
such  as  that  there  is  a  conspiracy  against  him,  that  his 
friends  put  poison  in  his  food,  or  that  every  little  annoyance 
is  planned  for  the  purpose  of  irritating  him. 

(e)  Delusions  of  unseen  agency.  This  form  of  delusion  is  not 
always  so  easily  detected,  because  the  patient  is  often 
suspicious,  sometimes  as  if  he  half  doubted  his  own  judg- 
ment, and  he  is  therefore  not  always  willing  to  speak  of  it. 
He  may  apparently  be  quite  rational  on  all  other  subjects. 
One  patient  complains  that  the  ward  in  which  she  is  placed 
is  a  battery,  which  is  being  made  to  work  on  her  system  so 
as  to  destroy  life.  Another  is  positive  that  the  newspapers 
publish  observations  charged  with  insulting  references  to 
himself,  although  no  rational  mortal  could  by  a  stretch  of 
imagination  see  where  the  insult  came  in.  A  further  example 
is  the  case  of  a  patient  who  believes  that  he  is  mesmerized, 
and  has  lost  his  personal  identity  through  the  machinations 
of  his  enemies. 

(/)  Delusions  of  identity.  The  daily  occurrence  of  cases  of 
m.'istaken  identity  in  the  world  at  large  makes  it  easy  for  us 
to  understand  how  readily  a  morbid  imagination  may  seize 
on  some  fancied  likeness,  and  so  entertain  a  delusion.  A 
mother,  having  lost  her  only  child,  brooded  over  her  loss, 
became  melancholic  and  suicidal,  was  sent  to  the  asylum, 
and  in  the  hospital  there  saw  a  young  girl  who  in  some  way 
may  resemble  the  lost  daughter,  for  the  mother  now  enter- 
tains the  delusion  that  this  is  her  lost  daughter,  and  nurses 
her  with  all  the  solicitude  and  care  that  a  mother's  love  can 
bestow.  This  is  a  delusion  of  personal  identity,  and  such 
are  very  common.  Doctors  and  nurses  in  asylums  are 
frequently  recognised  as  old  friends  and  called  by  wrong 
names  by  patients  who  have  never  seen  them  before.     Delu- 


DEPRESSION,  EXALTATION,  AND  ENFEEBLEMENT     57 

sions  of  identity  may  refer  to  person,  place,  or  sex,  either 
from  mere  suggestion  because  of  a  certain  resemblance,  from 
an  insane  association  of  ideas,  or  as  a  result  of  a  morbid, 
emotional  state.  The  identity  of  place  is  sometimes  in  fault, 
especially  in  acute  states  of  excitement  and  in  senile  cases. 
Delusions  of  sexual  identity  are  more  frequent  in  female 
insanity.  Women  (nurses,  for  example)  are  said  to  be  men 
masquerading  in  female  clothing.  This  form  of  delusion  is 
common  in  women  who  have  perverted  sexual  ideas. 

Depression  is  the  next  symptom  of  diagnostic  significance 
which  we  have  to  consider  :  that  state  of  misery,  unhappi- 
ness,  loss  of  the  sense  of  well-being,  which  has  previously 
been  referred  to,  where  there  is  no  longer  any  interest  in 
life,  no  care  taken  by  a  mother  for  her  household  or  children, 
an  utter  neglect  of  home  duties,  where  the  once-busy  house- 
wife sits  with  her  hands  in  her  lap,  her  head  drooping,  her 
attitude  and  expression  those  of  hopeless  despair.  It  is  the 
essential  symptom  of'  all  forms  of  melancholia,  and  is  often 
associated  with  depressing  delusions.  There  are  degrees  of 
depression,  from  the  passing  depression  of  dyspepsia,  or  liver 
derangement,  to  that  depth  which  takes  a  hold  of  a  man, 
masters  him,  and  paralyzes  his  best  energies,  and  it  is 
difficult  sometimes  to  draw  the  line  between  normal  and 
abnormal  depression. 

Exaltation  is  the  opposite  extreme  to  depression,  and  we 
regard  it  as  an  emotional  state.  We  meet  a  man  who  has 
been  hitherto  regarded  as  staid  and  sensible,  what  may  be 
called  solid  and  level-headed,  exhibiting  a  state  of  buoyancy, 
extravagance  of  demeanour,  hilarity,  and  absurd  self-conceit, 
without  any  cause  to  account  for  it  or  justify  it.  We  call 
this  state  exaltation.  He  has  large  ideas  of  his  own  import- 
ance, of  his  intellectual  capacity,  unbounded  confidence  in 
the  future,  indulges  in  extravagant  prophecies,  and  bets 
recklessly  without  a  moment's  hesitation.  Nothing  daunts 
him  ;  he  is  equal  to  any  occasion.  He  will  undertake  any- 
thing ;  the  whole  world  is  rose-coloured,  and  he  himself  is 
the  hub  of  the  universe.  The  man  is  in  a  state  of  insane 
exaltation.  As  with  depression,  so  also  with  exaltation, 
there  are  degrees  ranging  from  the  normal  up  to  the  abnormal. 


58  CLINICAL  MANUAL  OF  MENTAL  DISEASES 


and  common-sense  will  guide  us  in  drawing  the  line ;  but 
we  must  consider  these  states,  depression  and  exaltation,  in 
relation  to  other  mental  departures  from  the  normal,  such  as 
delusions  and  insane  impulses. 

Mental  Enfeehlenient. — This  refers  more  primarily  to  the 
condition  of  the  intellect,  but  there  is  suspension  or  diminu- 
tion of  all  the  mental  activities.  The  idiot,  the  imbecile, 
and  the  chronic  lunatic  are  mentally  enfeebled.  In  the  case 
of  the  idiot  and  the  imbecile,  the  higher  levels  have  never  been 
reached.  In  many  cases  there  has  been  the  bright  promise 
of  youth,  but  having  reached  a  certain  stage  of  development 
— probably  the  adolescent  —  an  acute  attack  of  insanity 
occurs,  and  exhaustion  and  mental  enfeeblement  are  the 
result.  Mental  enfeeblement  means  in  such  cases  a  prema- 
ture dissolution,  a  quick  decay  of  mental  constitution  ;  the 
memory  difficult  to  rouse,  and,  if  at  all  responsive,  slow, 
forgetful,  imretentive  ;  all  interest  is  lost,  little  notice  is  taken 
of  anything,  and  if  the  attention  is  wakened  up  for  a  moment, 
sustained  observation  is  impossible.  At  the  present  time  a 
young  man  is  copying  these  pages  who  is  in  a  state  of  partial 
mental  enfeeblement.  He  will  do  automatically  anything 
he  learned  before  his  attack  of  insanity  a  year  ago,  but  any 
marks  on  the  manuscript  signifying  '  new  paragraph,'  or 
complicated  alterations,  he  is  incapable  of  attending  to.  His 
memory  is  slowly  improving,  but  he  cannot  think  much, 
and  is  unable  to  do  such  a  sum  in  arithmetic  as  the  follow- 
ing :  '  If  a  hen  and  a  half  lay  an  egg  and  a  half  in  a  day 
and  a  half,  how  many  will  six  hens  lay  in  six  days  ?'  Next 
day,  when  asked  if  he  had  worked  it,  he  said  he  couldn't  ; 
asked  to  repeat  the  question,  he  repeated  it  without  a  mis- 
take. When  well  he  was  able  to  work  out  a  much  more 
difficult  question  without  trouble.  He  wants  mental  initia- 
tive ;  some  other  Will  must  start  him  to  work. 

The  emotions  and  moral  nature  are  not  in  evidence,  for 
the  mental  existence  is  negative.  You  find  that  the  love  of 
a  parent  for  his  child  has  lost  its  intensity,  and  is  now 
merely  automatic,  a  memory  of  the  past  ;  the  will  is  en- 
feebled, and  sometimes  the  impulses  break  out  unexpectedly 
without  any  coherent  explanation.     The  will  and  impulses 


DISORDERED  EMOTIONS  AND  INSTINCTS  59 


of  the  insane  are  responsible  for  many  things  said  and  done 
which  render  insanity  sensational  and  appalling.  If  the  will 
in  health  is  so  much  influenced  by  the  intellect  and  emotions, 
how  grave  its  possible  misdirection  when  influenced  by 
insane  ideas  and  emotions  !  Where  the  mental  balance  is 
lost  and  reason  dethroned,  the  insane  play  of  the  impulses  is 
supreme.  Thus,  under  insane  conditions  the  acts  a  man 
would  recoil  from  in  his  sober  senses  he  is  impelled  to  by 
insane  delusions  and  ungoverned  impulses. 

Disordered  emotions  and  instincts  are  freely  manifested  in 
many  cases  of  insanity.  A  mother  spurns  her  offspring, 
declares  the  child  she  has  just  given  birth  to  a  cat  or  dog, 
and  throws  it  into  the  fire  or  out  of  the  window ;  she  conceives 
an  unreasoning  hatred  of  her  husband,  and  lifts  a  poker  to 
break  his  head,  or  locks  him  out  of  the  house.  A  man  of 
intemperate  habits  becomes  incontinent  and  gives  way  to 
unbridled  passion,  or  conceives  a  dislike  to  his  wife,  out  of 
which  grows  suspicion  of  her  virtue,  and  then  an  impulse  to 
murder  her.  In  these  and  a  variety  of  ways  the  emotions 
and  instincts  betray  insanity. 

The  moral  faculty  also  exhibits  departures  which  are  as 
surprising  as  they  are  deplorable.  A  man  once  the  soul  of 
truth  and  honour  lies  unblushingl}-,  is  lost  to  all  sense  of 
personal  responsibility,  utterly  neglects  his  obligations,  and 
is  restrained  by  no  moral  consideration  whatever.  A  man 
whose  word  was  as  good  as  his  bond  is  not  to  be  depended 
on.  He  was  careful  in  giving  a  promise,  because  he  was 
always  scrupulous  in  keeping  it.  Now  he  will  promise  any- 
thing, and  be  utterly  indifferent  as  to  the  fulfilment.  Once 
too  proud  to  ask  a  loan,  he  now  borrows  and  never  pays. 
He  no  longer  can  distinguish  between  his  own  and  his 
neighbour's  property  ;  everything  he  can  lay  hands  on  now 
is  his  own.  Formerly  the  soul  of  honour  at  cards,  he  cheats 
without  any  conscience. 

Excitement. — The  diagnostic  value  of  this  symptom  de- 
pends on  the  amount  and  nature  of  excitement,  and  how 
far  it  is  rational  and  justifiable.  We  are  all  subject  more  or 
less  to  excitement,  and  the  cause  to  a  calm,  dispassionate 
outsider   is  often   quite  insufficient  to   account  for  our  dis- 


6o  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

turbance.  This  may  be  all  very  true  ;  but  it  is  no  diagnostic 
symptom  of  insanity,  for  the  simple  reason  that  all  men  are 
excitable  in  response  to  certain  mental  stimuli,  some  more, 
some  less.  To  some  men  a  longer  rope  is  allowed,  for  they 
are  naturally  more  mercurial,  and  the  worst  that  is  said  of 
them  is  that  they  are  always  excitable.  Joy  does  not  kill, 
we  are  told,  but  it  sometimes  drives  very  sober-minded  people 
crazy  with  excitement ;  and  we  have  heard  it  said  of  such 
a  man,  when  he  is  restless,  unsettled,  flighty,  noisy,  and  quite 
beside  himself,  that  he  is  '  off  his  head.'  Even  such  excite- 
ment is  not  a  diagnostic  symptom  of  insanity,  because  it  is 
soon  recovered  from,  and  the  man  is  quite  his  sober  self 
again.  When  excitement  is  unduly  prolonged,  when  it  is 
utterly  childish  in  its  extravagance  and  irrelevance,  when  it 
is  out  of  all  reasonable  proportion  to  the  cause,  and  when  it 
is  the  outcome  of  delusion  or  other  diseased  mental  state,  we 
have  to  take  note  of  it  as  probably  a  diagnostic  symptom  of 
some  importance.  In  considering  the  matter,  we  must  here 
again  remember  the  personal  equation.  In  making  astro- 
nomical calculations,  no  two  men  observe  and  register  with 
the  same  speed,  and  so  we  speak  of  a  personal  equation, 
which  has  to  be  taken  into  account  in  allowing  for  errors  in 
time-recording  observations.  The  personal  equation  must 
also  be  taken  into  account  in  making  a  record  of  insane 
symptoms ;  not  the  personal  equation  in  the  observer,  but  in 
the  observed,  and  this  is  particularly  necessary  in  taking 
note  of  excitement.  One  man's  sense  of  humour  will  excite 
him  so  that  his  neighbour  thinks  him  mad,  simply  because 
his  neighbour  has  no  sense  of  humour  at  all.  In  the 
theatre  we  have  noticed  a  young  man  laughing  out  of  time 
because  his  sense  of  humour  was  slow.  To  see  him  laughing 
hj^sterically  a  long  time  after,  when  the  play  had  reached 
a  tragic  stage,  might  suggest  insanity ;  but  this  would 
be  a  hasty  diagnosis,  and  we  must  allow  for  the  personal 
equation. 

Excitement  is  therefore  regarded  as  a  variable  quantity  in 
different  individuals,  and  as  a  statement  in  a  certificate  of 
insanity,  if  unsubstantiated  by  something  stronger,  would 
count  for  very  little.     Excitement  manifests  itself  in  activities 


EXCITEMENT  AND  INCOHERENCE  61 

of  mind  or  body,  in  extravagant  emotion,  tears  or  laughter, 
in  unlimited  indulgence  of  social  cravings,  perfervid  indul- 
gence of  imagination,  carrying  one  out  of  the  world  of 
ordinary  life  and  sense.  Excitement  may  show  itself  in  a 
state  of  muscular  unrest,  a  muscular  impulsiveness  to  do 
something,  no  matter  what,  or  go  somewhere,  no  matter 
where  ;  in  the  wringing  of  the  hands,  the  swaying  to  and  fro 
of  the  body,  the  restless  agitation  of  melancholy,  the  raging 
fury,  the  violence,  the  rushing  to  and  fro  of  the  maniac,  and 
the  incessant  thieving,  tearing  to  pieces  and  grovelling  of 
the  excited  general  paralytic.  Muscular  activity  is  often  a 
relief  to  mental  unrest,  the  boiling  over,  the  safety-valve,  the 
instinctive  outpouring  of  a  diseased  mental  state.  But  we 
must  remember  there  are  degrees  of  mental  and  muscular 
excitement,  and  that  under  the  influence  of  moderate  excite- 
ment we  may  have  mental  inspirations  and  great  physical 
achievements.  A  nerve  is  excited  when  it  conducts  an 
impression,  the  pulse  when  it  is  stimulated  ;  but  these  are 
normal  excitements.  So  also  is  that  of  the  brain  in  mental 
work.  The  nerves  may  vibrate  quickly,  the  pulse  beat 
frequently,  the  brain  work  at  high  pressure,  and  the  excite- 
ment is  normal  ;  but  sensibility  may  become  pain,  the  pulse 
may  become  rapid  and  intermittent,  and  the  brain  may 
ultimately  work  at  high  pressure  beyond  control.  Mental 
and  bodily  excitement  are  not  therefore  fixed  quantities,  and 
there  is  no  sharp  boundary-line  between  what  is  normal  and 
what  is  abnormal.  Abnormal  excitement  is,  however,  to  be 
discriminated  in  the  way  I  have  stated  by  comparing  the 
individual  with  himself,  and  by  allowing  for  what  may  be 
physiological. 

Incoherence. — This  is  a  symptom  which  must  also  be  dis- 
counted. When  a  man  is  normally  excited  he  is  sometimes 
incoherent,  and  I  need  not  say  that  when  a  man  is  drunk  he 
is  often  incoherent.  But  these  we  should  have  no  difficulty 
in  distinguishing  from  the  incoherence  of  insanity.  This  is 
a  very  important  symptom,  not  only  for  diagnosis,  but  in  the 
clinical  study  of  the  progress  of  a  case.  There  are  degrees 
of  incoherence.  A  man  may  merely  be  rambling  and  irrelevant 
in  his  conversation  or  answers  to  questions,.     He  may  not  be 


62  CLINICAL  MANUAL  OF  MENTAL  DISEASES 


able  to  fix  his  attention  lon^  on  one  topic  ;  he  may  be 
coherent  with  his  sentences,  but  incoherent  with  his  para- 
graphs. He  may  be  coherent  with  his  words,  and  not  with 
his  sentences.  Lasth;,  his  words  may  be  a  confused  jumble 
of  incoherence,  and  his  state  one  of  incoherent  delirium. 
We  shall  find  cases  of  acute  mania  where  we  have  all  these 
grades  represented  in  the  order  I  have  stated,  as  the  disease 
deepens  and  intensifies  ;  and  in  recovery  they  disappear  con- 
versely, a  beautiful  illustration  of  dissolution  with  mania, 
and  resolution  or  evolution  to  recovery. 

The  following  example  of  incoherence  was  taken  by  a 
shorthand  writer  as  the  words  fell  from  the  lips  of  an  acute 
maniac  : 

*  .  .  .  not  know  shorthand  :  but  I  say  draw  a  score,  but 
draw  it  right,  and  a  score  to  make  it  wrong.  He  does  not 
know  shorthand,  but  I  know  it.  Damn  it !  you're  gittering 
about  a  thing  you  know  nothing  about.  Damn  it !  if  you 
take  that  ;  but  he  does,  and  I  see  the  heads  of  that,  you 
being  so  damned  clever.  Well,  a  man  came  up  and  told 
me,  "  You're  mv  servant."  For  the  higher  officials,  for  the 
draught,  or  the  officials  for  this  man's  liberty.  Here  it  goes ; 
man  must  join  man  :  man,  Mr.  Dykes,  man  more,  and  the 
whole  lot  of  you,  and  the  whole  lot  of  the  liars  in  Edinburgh, 
Glasgow,  or  Scotland  !  Now,  you're  done.  It  will  be  in  for 
me  before  the  law.  Do  you  hear  that  ?  It  will  be  into  your 
ears  in  five  minutes.  That  is  the  way  he  keeps  it  from  you. 
W^eli,  you  are  free  on  your  own  condition,  and  you  are 
booked  ;  and  if  \ou  do  that  you  are  booked,  and  if  you  do 
not  withdraw  that  you  are  booked  as  sure  as  there  is  a  God 
in  heaven.  No,  the  God  in  heaven  will  strike  you  a  corpse  ! 
Is  it  three  or  four  ?  No  man  tipped  him,  no  man  brought 
him  back.  I  shall  answer  to  God.  I  will  tell  the  truth  that 
the  God  that  made  me  through  you  sees  it  put  down  in 
shorthand  that  this  man  has  been  witnessing  the  great 
murders  for  us — this  man  here,  you  are  aware.  Put  that 
down,  and  put  it  so  as  he,  the  other  one.  Of  course  he  has 
suffered ;  but,  of  course,  the  priest  says  that  those  who 
suffer  without — and  he  is  quite  aware  of  it — that  one  dose 


INSANE  CONDUCT  AND  PROPENSITIES 


is  enough  for  him,  that  there  is  forty-five  off  his  stipend;  and, 
says  he,  this  is  the  righteous  man  that  does  nothing,  and, 
says  he,  that  man  there  must  be  an  unrighteous  man,  and  this 
man  is  free  and  says  .   .   .   .' 

Insane  Conduct  and  Propensities. — There  ma}-  be  observed 
many  strange  exhibitions  of  conduct  and  erratic  propensities, 
and  we  wiU  be  puzzled  in  not  a  few  cases  by  the  entire 
absence  of  any  other  manifest  symptom  of  insanity,  for  fre- 
quently speech  is  restrained  or  abolished.  Insane  conduct 
shows  itself  in  so  many  inconceivable  wa}'s  that  it  is  hopeless 
to  attempt  a  catalogue  of  them.  We  see  it  in  dress,  in 
carriage,  in  behaviour  towards  others,  in  attitude  and  gestures, 
in  occupation,  dealings  with  property,  habits  as  to  food,  drink, 
and  amusement,  and,  lastly,  it  ma}-  be  in  mere  exaggerations 
of  previous  character.  We  find  the  insane  dressed  sometimes 
fantastically  in  supposed  keeping  with  their  insane  delusions 
of  position  and  wealth  ;  we  observe  the  swinging  gait  of 
insane  pride,  the  haughty  carriage  of  the  imaginary  king  or 
queen,  the  resentful  manner  when  anyone  inadvertently  rubs 
against  them,  the  attitude  of  listening  to  imaginary  voices, 
looking  at  imaginary  objects,  the  stand-off  gesture  of  one, 
the  gesture  of  fear  in  another.  We  observe  the  insane  man 
sometimes  make  ducks  and  drakes  of  his  property,  turning 
night  into  day,  wearing  at  one  time  three  coats  and  as  many 
vests  if  he  can  get  them,  refusing  his  food  under  the  belief 
that  it  is  poisoned,  drinking  alcohol  with  an  insane  thirst, 
eating  with  insane  gluttony,  or  gambling  with  insane  per- 
tinacity and  reckless  imprudence.  He  is  sometimes  seized 
with  a  desire  to  possess  everj^thing  he  sees,  and  scramble  for 
everything  he  can  possess,  no  matter  how  valueless  (klepto- 
mania) ;  he  is  sometimes  seized  with  an  impulse  to  burn,  or 
does  so  deliberately  under  the  influence  of  delusion  or  hallu- 
cination (pyromania).  Or,  again,  it  may  be  that  he  is  the 
victim  of  a  craze  to  tear  out  his  eyes,  pull  out  all  his  teeth, 
or  in  some  other  way  mutilate  and  maim  himself.  He  may 
be  wet  and  dirty  in  his  habits,  utterly  regardless  of  the  calls 
of  Nature,  and  lost  to  all  sense  of  decency,  even  to  the 
extent  of  going  about  stark  naked.  He  may  be  destructive 
of  clothes,  bedding,  furniture,  etc. 


64  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

Stdcidal  Propensity. — Suicide  is  not  necessaril)^  a  symptom 
of  insanity,  and  would-be  suicides  are  sometimes  sent  to 
prison  instead  of  to  asylums  ;  but  the  dividing-line,  even  in 
such  cases,  is  but  a  very  faint  one,  and  it  is  safer  to  regard 
this  propensity  as  indicating  a  morbid  state  of  mental  health. 
The  rate  for  males  is  greater  than  for  females,  but  where 
the  population  is  dense  the  discrepancy  is  less.  The  reason 
assigned  for  the  predominance  of  male  suicide  is  that  the 
struggle  for  existence  falls  more  heavily  on  the  male  sex  than 
on  the  female.  The  more  commonly  assigned  causes  of  male 
suicide  are  vices,  money  troubles,  and  tedium  vitce  {vide  Wynn 
Westcott),  whilst  females  are  impelled  to  suicide  by  their 
passions,  remorse  and  shame,  and  a  less  resisting  brain. 
The  largest  number  occurs  between  the  ages  of  forty  and 
fifty.  The  male  tendency  comes  to  its  maximum  after  forty, 
the  female  before  thirty.  It  is  not  common  in  childhood  ; 
but  cases  do  happen,  and  it  is  believed  to  be  on  the  increase 
as  a  result  of  our  present  system  of  education,  but  against 
this  is  to  be  placed  the  fact  that  the  abolition  of  corporal 
punishment  has  removed  one  fertile  cause  of  suicide  in  child- 
hood. 

Suicide  may  be  premeditated  or  due  to  sudden  unpre- 
meditated impulse.  When  premeditated,  the  spell  of  the 
suicidal  propensity  may  take  hold  of  a  man  for  a  long  time, 
sometimes  never  absoluteh'  leaving  him  ;  but  when  the 
result  of  impulse,  as  from  fear,  passion,  or  drink,  it  is  less 
likely  to  last  long,  as  the  mental  condition  is  a  changing  one, 
often  tending  naturally  to  recovery.  Any  patient  regarded 
as  suicidal  must  be  guarded  carefully,  but  as  unobtrusively 
as  possible.  It  is  better  also  not  to  relax  vigilance  too  soon, 
even  when  recovery  seems  assured.  We  must  be  on  guard 
against  quiet  cases,  those  apparently  intelligent  and  sensible, 
especially  if  they  are  depressed  and  have  no  pleasure  in  life, 
if  delusions  of  conspiracy  prevail,  or  hallucinations,  especially 
of  hearing,  e.g.,  that  a  voice  commands  them,  impels  them  to 
certain  actions.  Suicides  are  more  liable  to  occur  in  the 
morning,  because  depression  is  then,  as  a  rule,  most  acute. 
Remember  that  a  patient  who  fears  death  may  be  impelled 
by    this    fear    to    actually    destroy    himself.      The    methods 


SUICIDE  AND  HOMICIDE— OBSESSION  65 

adopted  in  the  order  of  their  frequency  are  hanging,  drowning 
(especially  with  women),  cut-throat,  poison,  firearms.  The 
relation  of  mental  health  to  physical  health  is  well  illustrated 
in  the  case  of  a  chronic  lunatic  who  had  parole  for  years,  and 
was  trusted  with  the  management  of  the  piggery.  News 
came  of  his  wife's  death,  and  he  seemed  only  temporarily 
upset.  Three  months  later  he  was  seized  with  bronchitis, 
and  took  to  bed.  He  became  mentally  depressed,  and  tried 
to  hang  himself  in  the  water-closet.  He  was  restored  to  life 
and  consciousness  after  a  strenuous  effort  on  the  part  of  the 
medical  men  in  the  asylum. 

Homicide. — Here  also  we  may  have  deliberate  or  impulsive 
attempts.  Deliberate  acts  appear  usually  as  the  result  of 
delusion  or  of  long-smouldering  passion.  The  impulsive 
attacks  are  made  by  the  epileptic,  the  masturbator,  and 
those  subject  to  hallucinations.  It  is  difficult  always  to 
determine  how  far  deliberation  can  be  assigned  to  a  suicidal 
or  a  homicidal  act,  but  it  is  probable  that  such  impulses  are 
sometimes  the  result  of  a  gradual  mental  change  going  on 
for  some  time  before — a  growing  intensity  of  feeling,  of 
which  the  apparent  impulse  is  the  final  exactment.  I  have 
one  case  under  asylum  treatment,  a  determined  masturbator, 
who  acts  as  mason's  labourer,  and  is  a  most  useful  man. 
He  indulges  m  self-abuse  every  morning,  and  for  some  hours 
afterwards  is  so  dangerous  that  he  has  to  be  kept  in  the 
asylum  till  after  breakfast.  By  that  time  he  has  cooled 
down,  and  is  safe  to  go  out  to  work.  He  is  a  case  of 
impulsive  homicide.  Where,  then,  we  have  delusions  of 
persecution,  intense  irritability,  epileptic  mania,  hallucina- 
tions especially  of  hearing,  or  masturbation,  we  should  be 
prepared  for  homicidal  attacks. 

Obsession. — This  term  has  been  introduced  as  a  substitute 
for  the  older  phrase,  imperative  conception,  or  imperative 
idea ;  and,  like  many  symptoms  of  insanity,  it  has  to  be  care- 
fully distinguished  from  apparently  similar  symptoms  common 
in  the  sane  mind.  The  word  '  obsession '  is  regarded  by  some 
authorities  as  synonymous  with  nightmare,  and  a  recollection 
of  the  chief  features  of  this  distressful  state  will  help  us  to 
understand  the  use  of  the  term  '  obsession  '  in  psychological 


66  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

medicine.  In  nightmare  there  is  a  terrorizing  idea,  e.g., 
falHng  over  a  precipice  or  a  railway  smash,  and  a  paralysis 
of  will  :  speech,  movement  of  any  kind  is  impossible. 

Obsession  means,  in  the  first  place,  that  condition  of  mind 
in  which  unwelcome  thoughts  obtrude  themselves  in  spite  of 
the  antagonism  of  the  will.  They  predominate  imperatively, 
so  that,  however  much  the  will  tries  to  divert  thought  in 
another  direction,  it  fails. 

Such  a  condition  of  mind  everyone  has  experienced,  but 
obsession  means  more.  It  means  a  conscious  effort  to  prevent 
such  thoughts  taking  possession  of  the  mind,  a  conscious 
effort  to  defeat  insane  impulses,  a  distressed  state  of  mind, 
because  these  thoughts  or  impulses  are  overmastering,  and 
a  feeling  of  relief  only  when  this  distressing  state  of  mental 
tension  has  been  relieved  by  giving  up  the  struggle  and 
letting  the  imperative  idea  or  impulse  have  its  own  way. 

Illustrations  might  be  given  ad  libitum.  I  remember  an 
old  gentleman  whose  life  was  one  constant  mental  torture, 
trying  to  recollect  names.  He  couldn't  work,  eat,  sleep,  or 
think  of  anything  else,  and  he  spent  several  days  and  nights 
of  deplorable  misery  trying  to  remember  the  name  of  a  river 
in  Fife.  Various  fears  are  classed  here :  agorophobia  (fear 
of  open  spaces),  claustrophobia  (fear  of  narrow  or  close 
spaces),  acrophobia  (fear  of  high  places),  and  many  others. 

Many  homicidal  and  suicidal  impulses  are  true  obsessions. 
One  gentleman  could  not  sit  at  table  with  his  family,  for  a 
homicidal  idea,  suggested  by  the  knives,  at  once  dominated 
him,  and  he  had  to  seek  refuge  in  an  asylum,  so  great  was 
his  anguish  and  dread  of  giving  way. 

Aboulia  is  an  extreme  state  of  volitional  weakness,  or,  as 
the  name  indicates,  loss  of  will;  there  is  inability  of  the  will 
to  act,  and  there  is  distress  because  of  this.  One  of  the 
most  frequent  forms,  as  stated  by  Regis,  is  the  inability  of 
a  patient  to  rise  from  a  sitting  posture.  As  a  matter  of 
fact,  the  explanation  of  some  actions  being  more  easily 
accomplished  than  others  is  that  less  volition  is  required. 

The  volitional  energy  required  by  tramway  horses  to  start 
the  car  is  greater  far  than  that  required  to  keep  it  running. 
It  requires  less  volition  to  let  a  hand  fall  than  to  raise  it,  to 


ABOULIA  — VERBIGERATION  67 

sit  down  than  to  rise  up.  Aboulia,  and  obsession,  which  is 
a  variety  of  it,  are  conditions  which  come  and  go,  there  being 
an  ebb  and  flow  of  the  intensity. 

Verbigeration  is  an  affection  of  speech  not  uncommon  in 
the  insane,  consisting  in  the  monotonous  repetition  of  the 
same  words  or  sounds  or  sentences,  without  any  mental  con- 
ception or  stimuhis  to  account  for  them.  A  very  intelhgible 
example  is  given  in  Tuke's  '  Dictionary  of  Psychological 
Medicine.'  A  female  patient,  who  constantly  stationed  her- 
self at  the  main  gate  of  the  asylum,  used  to  call  out  all  the 
day  long  to  every  passer-by,  whether  physician,  attendant, 
or  fellow-patient,  '  Please,  my  golden  doctor,  do  give  me  the 
keys.'  For  the  sake  of  experiment,  the  keys  were  given  her, 
but  this  did  not  stop  her  monotonous  speech.  To  enter  in  the 
journal,  'The  patient  constantly  stations  herself  at  the  door, 
wants  to  get  hpme,  and  asks  for  the  keys,'  would  be  incorrect. 
Verbigeration  is  found  in  several  mental  states,  in  chronic 
insanity,  states  of  stupor,  and  in  the  epileptic  and  general 
paralytic. 


5—2 


CHAPTER  V. 

CA  USA  TION— PROGNOSIS— TRE A  TMENT. 

Causation— The  wide  significance  of  heredity— Insanity  of  the  degenerate 
— Statistics  of  heredity — Predisposing  and  exciting  causes  discussed 
—Examples  of  such — Prognosis  affected  by  heredity— Previous 
attacks — The  cause  of  the  attack — The  nature  of  the  onset — The 
question  of  physical  complications — Functional  and  organic  condi- 
tions—The mental  character,  and  the  habits  of  the  patient— General 
Principles  of  Treatment  in  private  practice  and  in  asylums — The 
advantages  of  each  compared,  and  their  disadvantages — The  cases 
that  do  best  in  private  practice,  and  those  which  should  be  sent 
to  asylums. 

Causation. 

The  causation  of  insanity  is  one  of  the  most  perplexing 
problems  of  the  whole  subject.  Much  has  already  been 
said  and  written  with  a  lack  of  caution  that  is  to  be  re- 
gretted, and  the  general  public,  as  a  result,  imagine  they 
know  all  about  it,  and  that  two  factors  account  for  everything 
— heredity  and  alcoholic  excess.  The  discussion  of  the 
whole  question  would  lead  us  far  afield — too  far  for  a  work 
of  this  size — but  we  may  with  great  advantage  take  a  broad 
view  of  the  subject,  albeit  we  must  make  it  a  cursory  one. 
It  is  quite  true  that  heredity  plays  an  important  part  in  the 
causation  of  insanity,  but  we  have  to  remember  that  heredity 
is  a  factor  of  variable  quantity  and  distribution.  Going 
back  through  the  history  of  the  ancestors,  we  will  come  to  a 
time  when  there  was  no  insanity,  and  yet  the  seed  might  be 
germinating  and  propagating  generation  after  generation 
until  the  outward  signs  became  manifest,  perhaps  at  first  in 
a  mild  form,  although  there  is  nothing  certain  as  to  the 
manner  or  degree  of  a  first  appearance,  or  the   number  of 


THE  WIDE  SIGNIFICANCE  OF  HEREDITY  69 

individuals  likely  to  be  affected.  It  may  appear  in  one 
member  alone,  oi"  several  may  be  affected  differently.  The 
first  sign  may  be  dipsomania,  epilepsy,  or  some  other  nervous 
disorder,  or  unmitigated  insanity  at  the  outset.  Following 
this,  we  will  probably  find  insanity  a  more  marked  feature  of 
the  family  history  thereafter,  but  in  no  two  cases  is  the 
starting-point  or  the  angle  of  deviation  the  same. 

The  individual  germ  has  subtle  potentialities  which  we 
cannot  fathom.  A  whole  host  of  accentuating  influences 
may  determine  a  rapid  departure  at  a  tangent  from  the 
normal,  and  the  individual  in  whom  this  occurs  may  be  the 
family  scapegoat,  or  the  morbid  influence  may  be  widespread, 
so  that  there  is  a  diffuse  family  contamination  less,  or  dif- 
ferently, accentuated  in  each  individual.  On  the  other  hand, 
a  whole  host  of  modifying  influences  may  determine  results 
precisely  the  opposite,  and  ultimately  the  germ  of  possible 
insanity  may  disappear  altogether.  Heredity  is  thus  a 
variable  quantity.  It  is  a  bias  which  may  be  moderated  by 
favourable  circumstances,  and  its  force  does  not  necessarily 
accumulate  as  time  goes  on.  The  dose  in  one  family  maybe 
larger  than  in  another.  The  family  may  be  extinguished,  or 
it  may  recover  by  a  new  tangent,  and  come  again  more  into 
the  normal  line.  When  heredity,  so  to  speak,  tightens  its 
grip  of  a  family,  the  tendency  is  for  each  succeeding  genera- 
tion to  succumb  earlier  than  the  preceding.  Thus  does 
Nature  eventually  wipe  out  the  mental  weaklings.  Looking 
at  the  matter  broadly,  we  are  not  justified  in  saying  that 
because  one  man's  father  was  insane,  and  he  afterwards 
becomes  insane  himself,  he  only  possesses  heredity,  while 
the  man  who  becomes  insane,  and  whose  forbears  exhibited 
no  evidence  of  insanity,  possesses  no  heredity.  The  germ 
may  lurk  unsuspected  in  a  previous  generation. 

The  next  question  is.  In  what  way  does  this  heredity 
manifest  itself  in  the  mental  constitution  and  character  of 
the  individual  ?  It  may  do  so  by  arrest  of  mental  develop- 
ment, idiocy,  imbecility,  mental  weakness,  or  moral  insanity. 
It  ma}^  do  so  by  a  subtle  indistinguishable  deviation  from 
the  normal  which  is  not  noticeable  at  birth,  but  which  is 
made  gradually  manifest  as  youth  springs  into  manhood,,  if 


yo  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

not  earlier.  The  deviation  has  no  clear  dramatic  starting- 
point.  It  is  essentially  a  part  of  the  man  himself,  and  must 
ultimately  develop  into  a  monomania  or  partial  insanity  of 
some  kind  or  other. 

You  will  find  in  practice  many  cases  which  call  for  decisive 
treatment  in  asylums  some  day  after  they  have  reached 
maturity,  or  during  the  period  of  adolescence  ;  and  you  will 
say  to  yourself,  'That  man  was  never  like  other  men,'  but 
you  could  not  hitherto  say  that  man  was  insane  ;  and  no 
one  could  put  his  finger  on  an3/thing  in  particular  and  say, 
'  Here  are  distinct  symptoms  of  insanity.'  The  man's  mental 
constitution  and  character  was  developed,  to  all  intents  and 
purposes,  like  that  of  other  men,  so  far  as  the  ordinary 
observer  could  see ;  but  a  certain  bias  vv^as  given  to  the 
mental  development  at  birth,  and  the  deviation  became  more 
apparent  as  time  went  on.  Such  cases  are  necessarily  in- 
curable, because  the  germ  was  there  and  active  at  the  outset 
of  their  career,  and  the  insanit}^  is,  so  to  speak,  their  normal 
and  essential  character. 

This  brings  us  to  the  consideration  of  a  term  which  has 
been  introduced  of  late  years  by  Legrain,  viz.,  the  insanity 
of  the  degenerate  instead  of  hereditary  insanity.  The  term 
'  degenerate  '  has  a  very  objectionable  suggestion,  and  must 
necessarily  include  many  criminals  in  this  class.  Moreover, 
it  is  made  to  include,  not  only  low  forms  of  degeneracy 
attended  with  physical  deformities  and  asymmetry  and  all 
forms  of  mental  weakness  down  to  idiocy  (vide  Tuke's 
'  Dictionary  of  Psych.  Med.'),  but  also  'the  mental  condition 
of  the  highest  form  of  the  degenerate,'  '  which  is  consistent 
with  great  intelligence.'  Indeed,  as  the  late  Dr.  Hack  Tuke 
observed,  '  there  seems  to  be  a  danger  of  employing  the 
term  "  degeneration  "  in  so  comprehensive  a  sense  as  to  com- 
prise forms  of  mental  disorder  under  one  head  which  differ 
widely  in  their  form,  their  prognosis,  and  their  treatment.' 
The  term  '  degenerate '  should  be  limited  to  those  cases  where 
heredity  is  so  overwhelming  that  idiocy,  imbecility,  mental 
weakness,  or  moral  insanity  is  obvious  in  early  youth ;  but 
'  insane  heredity  '  should  be  the  term  retained  for  cases  of 
acquired  insanity,  and  also  for  those  just  described  who  have 


INSANE  HEREDITY  7i 


from  youth  onward  slowly  and  insidiously  displayed  an  insane 
tendency,  but  who  are  in  many  respects  as  mentally  capable 
as  their  fellows. 

Heredity  may  show  itself  in  a  sudden  mental  breakdown 
due  to  any  exciting  cause  of  itself  insufficient  to  produce 
insanity.  The  mental  resistance  varies  in  different  indi- 
viduals, and  as  the  degree  of  resistance,  so  is  the  mental 
stability.  Many  causes  are  given  as  capable  of  producing 
insanity,  and  the  fact  that  they  fail  in  some  cases  and 
succeed  in  others,  all  other  things  being  equal,  shows  that 
the  degree  of  resistance  varies  in  different  individuals.  There 
are  many  insane  people,  on  the  other  hand,  who  have  been 
subjected  to  greater  strain  than  their  more  fortunate  fellows, 
and  placed  under  the  same  favourable  conditions  they  would 
never  become  insane.  The  degree  of  resistance  and  strain 
must,  therefore,  be  taken  into  account.  It  is  also  true  that 
many  lives  are  victims  because  of  their  unselfishness,  their 
high  moral  tone,  and  their  noble  if  sometimes  misguided 
sense  of  duty,  while  many  escape  because  they  are  sufficiently 
selfish  to  take  care  of  themselves  and  not  too  selfish  to  be 
viciously  self-indulgent. 

From  all  these  considerations,  we  must  gather  that  '  here- 
ditary predisposition  '  is  a  very  wide  term,  that  it  should  not 
strictly  mean  that  there  has  been  insanity  in  a  direct  or 
collateral  ancestor,  but  merely  that  in  one  or  more  previous 
generations  pathogenic  influences  have  been  accumulative.' 
The  influence  of  heredity,  as  we  have  been  accustomed  to 
speak  of  it  in  a  narrow  sense,  is  differently  brought  out  by 
different  writers.  Although  not  usually  quoted  in  statistics 
of  insane  heredity,  it  must  be  remembered  causes  may  be 
assigned,  such  as  epilepsy,  alcoholic  excess,  and  masturba- 
tion, which  may  themselves  be  due  to  heredity,  though 
insanity  as  such  has  not  until  now  made  an  appearance  in 
any  generation.  Insanity  must  have  a  beginning,  and  when 
it  does  begin  in  the  family  tree,  who  dares  say  that  there  is 
no  hereditary  disposition  ?  We  will  find  the  first  evidence 
of  it  often  in  the-  child,  the  father  or  mother  giving  evidence 
of  insanity  for  the  first  time  later  on.  And  we  will  find 
insanity,  like  consumption,  escaping  a  generation. 


72  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

In  255  cases  out  of  1,276  persons  admitted  to  asylum 
treatment,  I  found  a  clear  antecedent  family  history  of 
insanity  in  one-fifth,  and,  from  what  has  been  said,  we  can 
understand  that  this  does  not  represent  the  full  measure  of 
hereditary  weakness,  because  only  antecedent  insanity  is 
here  reckoned,  and  minor  departures  from  the  normal  are  not 
recorded.  Besides,  it  is  difficult  to  get  the  whole  truth  from 
friends,  and  a  complete  history  by  the  family  medical  man 
is  often  a  thing  impossible.  A  larger  proportion  of  my 
female  patients  were  hereditary  cases,  25  per  cent.,  and  only 
17  per  cent,  of  the  males.  The  statement  of  Baillarger,  that 
maternal  heredity  is  three  times  more  common  than  paternal, 
is  not  borne  out  by  my  statistics,  the  maternal  being  only 
20  per  cent,  in  excess. 

We  may  now  at  this  stage  compare  the  statistics  of 
different  ages  with  and  without  known  heredity,  and  the 
following  chart,  compiled  from  the  experience  of  fifteen 
years,  furnishes  a  graphic  and  instructive  illustration. 

This  chart,  illustrating  the  general  rise  and  fall  in  the 
percentage  of  insanity  of  all  ages,  and  side  by  side  the  rise 
and  fall  of  heredity  at  corresponding  periods,  shows  that  the 
maximum  of  insanity  is  reached  in  the  fourth  decade,  and 
the  maximum  of  heredity  before  the  age  of  twenty-five.  It 
shows  also  that  heredity  is  the  predominant  factor  up  to  the 
age  of  thirty,  and  thereafter  it  is  more  subordinate,  being  of 
least  account  between  the  ages  of  forty-one  and  fifty,  but 
gradually  rising  in  importance  thereafter  as  age  advances. 

The  causes  of  insanity  are  of  two  kinds — predisposing  and 
exciting ;  but  a  sharp  distinction  is  not  always  possible 
between  the  two,  because  the  predisposing  is  sometimes  also 
the  exciting  cause,  and  vice  versa.  Heredity  is  the  chief 
predisposing  cause  of  insanity,  and  allied  to  heredity  in  this 
sense  are  previous  attacks  of  insanity.  Where  there  is  no 
clear  evidence  of  heredity,  an  attack  of  insanity  itself 
establishes  a  predisposition,  and  it  may  be  accepted  as  a 
general  rule  that  the  more  frequent  the  occurrence  of  attacks, 
the  less  becomes  the  resistance  to  any  given  exciting  cause. 
To  this  there  are  exceptions,  as  in  puerperal  and  other 
conditions  ;  for  the  physical  health  may  be  up  to  par  at  one 


PREDISPOSING  AND  EXCITING  CAUSES 


73 


CHART  ILLUSTRATING  THE  RISE  AND  FALL  IN  THE 
PERCENTAGE  OF  INSANITY  OF  ALL  AGES,  AND 
SIDE  BY  SIDE  THE  RISE  AND  FALL  OF  HEREDITY 
AT  CORRESPONDING  PERIODS. 


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Unbroken  line  indicates  the  general  percentage  of  rise  and  fall. 
Broken  line  indicates  percentage  of  heredity. 


74  CLINICAL  MANUAL  OF  MENTAL  DISEASES 


time,  and  not  at  another.  To  the  general  rule  add  '  other 
things  being  equal.' 

Epilepsy  and  masturbation  are  examples  of  conditions  due 
to  heredity,  which  may  be  predisposing  or  exciting  causes. 
As  a  rule,  they  belong  more  to  the  predisposing  period,  and 
are  only  ver}^  rarely  elements  of  the  exciting  cause.  One 
more  example  of  a  predisposing  cause  is  long-continued  ill- 
health,  and  it  may  be  the  exciting  cause  as  well,  the  last 
step  in  the  down  grade  liberating  the  morbid  energy,  being 
like  the  last  drop  in  the  bucket  which  causes  it  to  overflow. 

Exciting  causes  are  those  which  operate  by  precipitating 
an  attack.  They  may  be  sufficiently  powerful  of  themselves 
to  produce  insanity,  even  if  a  man  is  not  streaked  with 
heredity  at  all.  Of  such  the  most  obvious  is  alcohol.  But 
when  alcohol  has  been  operating  insidiously  on  the  chronic 
soaker  for  years,  and  his  mind  becomes  affected,  it  is 
difficult  often  to  say  how  far  alcohol  has  predisposed  the 
man  to  mental  breakdown,  or  how  much  it  has  precipitated 
the  event.  We  must  carefully  study  the  history  of  the  man, 
and  his  social  life.  A  medical  Sherlock  Holmes  would  be 
invaluable  for  the  unravelling  of  the  tangled  threads,  the 
puzzling  mazes,  of  the  life-histories  of  many  of  the  insane. 
Observe  the  mental  change  in  this  chronic  soaker,  who  may 
ultimately  become  insane.  His  moral  sense  is  blunted,  his 
intellect  is  less  acute,  his  memory  confused,  and  he  may 
have  strange  sensations  and  become  suspicious  of  conspiracy, 
e.g.,  of  the  intrigues  of  women,  without  any  reasonable 
cause  ;  or,  because  of  his  mental  susceptibility,  the  ordinary 
circumstances  of  life  may  suggest  the  most  outrageous  ideas. 
The  soil  for  an  outbreak  is  prepared,  and  any  circumstance 
may  be  enough  to  start  the  outward  manifestations  of  disease. 
If  it  is  the  loss  of  a  child,  we  say  the  alcohol  predisposed, 
and  the  loss  of  the  child  excited  the  disease.  The  fact  is 
that  cause  and  effect  are  continuously  going  on  in  all  our 
lives ;  influences  physiological  ,  register  gain,  influences 
pathogenic  register  loss.  It  is  one  long  series  of  sequences, 
and  where  the  pathogenic  predominate  and  insanity  results, 
the  last  in  the  chain  is  said  to  be  the  exciting  cause.  The 
question  of  predisposing  or  exciting  is  one  of  time  occurrence, 


PROGNOSIS  75 


and  the  potency  of  each  will  vary  in  every  case.  In  speak- 
ing as  follows  of  exciting  causes,  we  will  now  be  prepared  for 
the  statement  that  the  term  exciting  is  convenient  and  elastic, 
rather  than  strictly  accurate. 

It  has  been  customary  to  speak  of  moral  causes,  and  to 
include  as  such  anything  having  a  serious  emotional  effect 
on  the  individual.  The  term  has  been  so  long  in  use  that 
it  may  be  retained ;  but  it  is  also  allowed  a  rather  elastic 
license.  Of  causes  coming  within  this  category  the  number 
is  very  great,  but  for  typical  examples  of  them  we  may 
quote  domestic  trials,  loss  of  relatives  or  friends,  unfortunate 
love  affairs,  strikes  and  their  evil  effects,  hardship  and  ex- 
posure, solitary  imprisonment,  losses  in  business,  fright, 
surgical  shock.  Some  of  these  act  in  a  physical  as  well  as 
in  a  moral  sense. 

Toxsemic  conditions  are  frequently  in  evidence  in  the  role 
of  exciting  causes — alcoholism,  chronic  poisoning  by  drugs, 
such  as  opium,  cannabis  indica,  and  cocaine,  the  gouty,  rheu- 
matic, and  syphilitic  states,  septicaemia  (especially  puerperal), 
influenza,  and  many  others,  some  of  them  less  known  and 
less  frequent. 

The  following  may  be  taken  as  examples  of  physical  causes 
other  than  toxaemic :  exhaustion  and  anaemia,  sunstroke, 
injury  to  head  or  spine,  and  the  changes  of  evolution  and 
dissolution  at  the  critical  epochs  of  life. 

Prognosis. 

This  is  of  great  importance.  i\.  man's  position  in  life,  the 
future  of  his  business,  the  ordering  of  his  household  affairs, 
the  education  of  his  family — these  and  many  other  equally 
important  decisions  are  contingent  on  prognosis  ;  and  many 
serious  perplexities  regarding  the  future  would  be  quickly 
solved  if  the  prognosis  were  sure  in  the  case  of  the  patient, 
male  or  female. 

An  accurate  diagnosis  is  often  a  much  more  simple  matter 
than  a  sure  prognosis,  and  of  late  years  the  subject  of  prog- 
nosis has  been  very  fully  discussed,  with  a  view  to  rendering 
it  more  positive  and  reliable.     There  is  grave  risk  in  prophe- 


76  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

sying  with  absolute  certainty  at  an  early  stage  of  mental 
disease,  and  above  all  in  prophesying  unfavourably,  because 
apparently  similar  cases  have  proved  intractable  and  incurable 
in  past  experience.  In  considering  the  question  of  prognosis, 
several  points  may  be  raised  by  the  friends,  if  not  by  the 
physician.  You  may  be  asked,  '  Will  the  patient  recover  ?' 
If  you  answer  cautiously  and  with  reserve,  you  may  then  be 
asked,  '  Will  he  recover  a  sufficient  amount  of  reason  and 
self-control  to  justifv  his  being  set  at  liberty,  and  being 
allowed  a  certain  amount  of  responsibility  outside  ?'  For 
business  or  other  reasons  you  may  be  asked,  in  a  mentally 
hopeless  case,  'How  long  is  he  likely  to  live?'  If  the 
patient  recovers,  you  may  be  asked  the  question,  '  Is  the 
attack  likely  to  recur,  and  how  soon  ?' 

In  considering  what  3'our  prognosis  will  be,  you  must  first 
determine,  if  you  can,  what  has  been  the  cause  of  the  mental 
attack.  If  it  has  been  heredity,  you  must  decide  what  bear- 
ing this  has  on  the  probable  course  of  the  disease.  At  one 
time  it  was  considered  that  patients  with  inherited  taint 
were  more  incurable  than  those  without ;  but  it  is  now 
generally  conceded,  as  the  result  of  experience,  that  the 
chances  are  better  on  the  whole  for  such  cases  than  for 
those  having  no  hereditary  taint,  but  with  this  reservation, 
that,  their  brains  being  more  unstable,  they  are  more  liable 
to  a  recurrence  of  the  disease.  If  a  patient  has  had  attacks 
before,  the  chances  of  recovery  diminish  with  every  succeed- 
ing attack,  and  the  tendency  usually  is  towards  dementia. 

Causes  mental  (moral)  and  physical  must  now  be  con- 
sidered in  their  bearing  on  prognosis.  As  a  rule,  mental 
causes  are  not  of  themselves  of  great  significance.  Their 
gravity  is  deepened  when  they  affect  individuals  whose 
normal  state  of  feeling  has  a  distinct  bias  towards  the 
abnormal.  A  man  who  has  never  known  what  it  is  to  be 
hilarious,  or  even  moderately  happy,  a  man  of  bilious 
temperament  and  with  an  everyday  state  of  feeling  which 
is  slightl}'  depressed,  is  more  likely  to  give  way  with  less 
hope  of  restoration  than  a  man  of  more  elastic  and  vivacious 
temperament.  In  computing  the  prognostic  influence  of 
causes,  it  is  well  to  remember,  and  it  is  here  stated  once  for 


PROGNOSIS  77 

all,  that  no  single  factor  should  guide  you  to  a  decision. 
As  with  diagnosis  and  causation,  the  patient's  case  should 
be  considered  in  all  its  bearings. 

Where  physical  conditions  can  be  found  to  have  had  a 
profound  influence  in  the  production  of  the  disease,  if  they 
can  be  removed,  that  counts  for  so  much  in  favour  of  a  good 
prognosis.  Many  forms  of  bodily  disease  accompany  insanity, 
and  in  the  hospital  wards  of  asylums  a  great  proportion  of 
the  mental  cure  is  obtained  by  ordinary  hospital  treatment. 
The  prognosis  of  the  bodily  disease  is  often  to  a  considerable 
extent  the  prognosis  of  the  mental.  If  the  patient  is  afflicted 
with  phthisis,  especially  if  it  is  progressive  and  pyrexial,  the 
prognosis  is  not  good  ;  but  if  it  is  latent  and  the  patient 
does  not  lose  weight,  but  rather  gains,  the  prognosis  is  more 
favourable.  If  you  lind  constipation  a  well-marked  condi- 
tion, and  that  it  has  not  been  a  habit  of  long  duration,  the 
prognosis  is  good,  providing  the  mental  disease  is  functional, 
not  organic.  I  have  several  times  been  astonished  at  the 
remarkable  results  obtained  in  the  treatment  of  cases  where 
the  mental  symptoms  were  severe,  and  the  prognosis  seemed 
otherwise  grave,  by  relieving  a  loaded  state  of  the  bowels. 
In  puerperal  insanity  this  loaded  condition  of  the  bowels  is 
sometimes  found.  It  has  been  also  found  in  acute  cases 
where  the  exciting  cause  or  causes,  e.g.,  bereavement  and 
religious  excitement,  obscured  and  overshadowed  everything 
physical,  so  that  utter  neglect  of  the  ordinary  laws  of  nature 
was  the  result,  and,  of  course,  neglect  of  the  primce  vice. 
There  are  also,  as  examples  of  physical  conditions,  septicaemia, 
sometimes  of  a  very  mild  character,  anaemia,  and  reduced 
health  from  exhausting  conditions  or  from  hard  times. 

You  may  lay  it  down  as  a  safe  rule  that,  whenever  you 
can  account  for  the  onset  of  insanity  by  pointing  out  causes 
which  are  removable,  or  when  there  are  physical  conditions 
accompanying  the  disease,  which  cannot  of  themselves  be 
favourable  to  mental  health,  and  when  you  can  remove 
these  causes  or  physical  conditions  by  medical  treatment, 
hygiene,  proper  dieting,  and  so  forth,  the  prognosis  is  in  so 
far  favourable.  Increase  of  weight  is  a  good  sign  if  there  is 
with  it,  or  soon  after,  an  amelioration  of  acute  symptoms 


78  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

and  a  restoration  of  sleep,  or  in  melancholia  of  the  quiet 
kind  if  there  is  a  disposition  to  work  or  be  interested  in 
others.  But  you  must  be  guarded  here  also.  Increase  of 
weight  is  usually  registered  before  there  is  any  appreciable 
sign  of  mental  improvement,  and  it  may  herald  dementia  as 
well  as  recovery.  It  is  still  a  moot  point  whether  recovery 
is  more  likely  to  take  place  in  males  than  in  females.  Ac- 
cording to  some  authorities,  the  advantage  is  with  males, 
and  according  to  others  it  is  with  females.  It  is  certainly 
true  that  organic  disease  is  less  frequent  among  females  than 
males,  and,  pro  tanto,  the  chances  of  recovery  are  better  for 
females. 

It  is  next  important  for  you  to  decide  whether  the  case  is 
one  of  functional  or  organic  disease.  The  term  '  functional ' 
is  here  used  in  a  relative  sense,  because  it  is  impossible  that 
there  should  be  disease  without  some  organic  change,  even 
if  it  is  microscopic  and  transitory.  The  chances  of  recovery 
are  greater  in  functional  cases  than  in  organic.  Of  the  latter 
may  be  mentioned  general  paralysis,  tumour  of  the  brain, 
grave  syphilitic  lesions,  cerebral  softening,  and  so  forth. 

Masturbation  is  a  very  bad  sign,  but  the  case  is  not  abso- 
lutely hopeless,  if  there  is  a  history  of  its  only  being  an 
acquired  habit  of  recent  date.  I  have  known  men  who 
masturbated  and  admitted  it,  and  tried  to  defend  it  on 
physiological  grounds.  One  was  insane  and  recovered.  He 
was  a  medical  man,  and  practised  successfully  for  nearly 
twenty  years  afterwards.  The  prognosis  in  melancholia  may 
be  delayed  for  a  much  longer  time  than  in  mania.  Melan- 
cholic patients  have  been  known  to  recover  after  seven  years' 
insanity,  and  there  are  cases  on  record  where  recovery  has 
occurred  after  an  even  longer  period.  With  mania  there  is 
more  active  disease,  a  more  rapid  course,  and  the  recovery 
is  early  in  many  cases,  though  in  some  it  is  delayed ;  and 
where  the  symptoms  remain  acute  for  a  long  time,  there  is 
danger  of  death  from  exhaustion. 

It  is  usually  held  that  delusions  which  are  fixed  and  do 
not  change  from  day  to  day  are  a  b^  sign,  whereas  fleeting 
delusions  are  a  good  sign.  To  this,  of  course,  there  are 
exceptions.     In  general  paralysis  there  are  many  apparent 


PROGNOSIS  79 


delusions  to  which  I  have  already  referred  as  fleeting  rather 
than  fixed,  and  the  prognosis  here  is  very  grave.  The  dura- 
tion of  the  disease,  as  already  indicated,  is  of  importance 
in  estimating  the  probable  outcome  of  it.  The  longer  the 
duration  of  the  disease  or  its  cause,  the  worse  the  prognosis. 
The  nature  of  the  onset  is  also  an  important  point.  If  it 
has  come  on  suddenly,  the  chances  of  recovery  are  better, 
and  the  chances  of  a  quick  recovery  are  also  better.  The 
age  of  the  patient  will  also  assist  us  in  coming  to  a  conclu- 
sion. The  proportion  of  recoveries  among  the  young  is 
greater  than  among  older  people.  It  is  natural  to  suppose 
that  the  older  a  person  gets,  the  less  should  be  his  recuperative 
power ;  but  cases  of  recovery  are  known  even  among  senile 
patients,  and  they  are  not  at  all  infrequent  in  climacteric 
cases. 

Refusal  of  food  is  a  symptom  which  has  been  regarded  as 
of  some  importance  in  arriving  at  a  prognosis.  Too  much 
has,  perhaps,  been  made  of  it ;  but,  as  it  is  not  an  uncommon 
symptom  of  insanity,  and  as  its  causes  and  mental  accom- 
paniments var}',  some  useful  hints  may  be  obtained  by  a 
study  of  these  in  relation  to  the  course  of  the  disease.  The 
prognosis  is  reckoned  more  favourable  in  the  case  of  females 
refusing  food.  According  to  Dr.  H.  H.  Newington,  it  would 
seem  that  '  when  a  man  takes  to  refusing  his  food,  he  does  it 
with  some  object,  whereas  a  woman  would  do  it  with  no 
object  at  all — perhaps  simply  hysterically.'  This  must  be 
received  with  a  qualification.  Cases  of  very  persistent  re- 
fusal of  food  do  occur  in  the  insanity  of  females,  but  the 
records  of  long  periods  of  artificial  ingestion  refer  almost 
invariably  to  males.  My  first  case  was  an  old  soldier  who 
had  not  tasted  food  or  drink  for  seven  years,  and  I  had  a 
patient  some  years  after  who  was  fed  twice  daily  for  over 
two  years.  The  first  died  from  chronic  phthisis,  the  second 
partially  recovered.  Dr.  Henry  Sutherland,  who  has  written 
a  very  interesting  paper  on  the  subject,  regards  the  prognosis 
as  good  if  the  patient  takes  food  after  one  feeding  by  stomach 
or  nasal  tube,  or  if  refusal  is  due  to  a  removable  cause,  such 
as  constipation,  dyspepsia,  etc.  He  says  the  prognosis  is 
bad  if  the  patient  loses  weight  steadily,  and  that  persistent 


8o  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

suicidal  refusal  of  food  is  an  unfavourable  sign.  With  regard 
to  the  last  two  statements,  a  reservation  must  again  be  made, 
and  you  require  to  be  cautious  in  pronouncing  unfavourably 
if  cases  of  that  kind  come  under  your  care,  as  I  have  had 
experience  of  such  with  excellent  recoveries.  You  must 
carefully  discriminate  between  mental  and  physical  causes 
for  refusing  food.  It  may,  like  the  mental  disease  itself,  be 
a  symptom  of  a  reduced  physical  condition,  with  physiological 
inertia  and  anorexia,  and,  when  the  cause  is  removed,  re- 
covery usually  takes  place,  the  patient's  voluntary  feeding 
being  one  of  the  first  favourable  signs.  Some  of  the  most 
hopeless  cases  are  those  who  refuse  food  under  the  influence 
of  dominating  delusions,  or  hallucinations.  Other  things 
being  equal,  the  prognosis  is  more  favourable  in  the  young 
than  in  the  old.  It  is  often  a  fight  between  a  keen,  craving 
appetite  and  a  mental  antagonism,  the  appetite  ultimately 
becoming  the  more  persuasive  of  the  two. 

General  Principles  of  Treatment. 

In  speaking  of  the  various  forms  of  insanity,  reference  will 
be  made  to  the  treatment  of  each  ;  but  there  are  general 
principles  which  apply  more  or  less  to  all  cases,  and  general 
instructions  on  treatment  may  be  introduced  here  with  great 
advantage  in  order  to  prevent  frequent  repetition.  We 
have  to  look  at  the  matter  from  two  points  of  view :  the  one 
is  that  of  private  treatment  in  private  houses,  and  the  other 
of  asylum  treatment  in  association  with  other  patients.  The 
general  practitioner  has  certain  advantages  over  the  asylum 
physician,  and  the  converse  also  holds  true.  In  general 
practice  there  is  the  advantage  of  getting  the  patient  at  the 
very  outset,  of  knowing  something  of  his  family  history  and 
his  own  individual  case,  and  of  seeing  the  first  premonitory 
signs  of  the  disease.  It  is  true  that  the  premonitory 
symptoms  are  not  always  apparent  even  to  the  family 
physician,  and  it  is  of  the  utmost  importance  that  he  should 
be  skilled  in  reading  the  signs  of  approaching  mental  disease, 
and  the  evidence  of  causes  which  may  possibly  bring  it  to 
pass.     A  great  deal  can    be    done    by  a   skilled    physician, 


GENERAL  PRINCIPLES  OF  TREATMENT  8i 

especially  if  he  is  in  the  family  confidence,  and  particularly 
in  the  confidence  of  the  patient,  in  averting  or  mitigating 
attacks  of  insanity. 

The  asylum  physician  has,  however,  some  advantages  over 
his  professional  brother  in  general  practice,  and  these  are 
asylum  discipline,  routine,  experienced  attendants  and 
nurses,  and  the  removal  from  the  obstructive,  though  well- 
meant,  interference  of  friends.  In  the  asylum  the  rules  are 
made  by  the  doctor,  and  his  orders  are  rigidly  carried  out. 
In  private  practice  the  doctor  may  make  what  rules  he  likes, 
but  he  has  not  always  the  guarantee  that  they  will  be  carried 
out.  Moreover,  in  private  practice  there  is  not  the  same 
facility  for  segregation  of  an  insane  patient,  for  removing 
him  to  a  place  where  he  will  neither  disturb  others  nor  be 
disturbed  himself,  for  giving  him  free  open-air  exercise  and 
manual  labour  away  from  the  obtrusive  curiosity  of  the 
senseless  crowd. 

In  coming  to  a  decision  as  to  what  you  should  do  in  a 
given  case  of  mental  disease,  you  have  two  points  to  keep 
before  you  :  First,  the  nature  of  the  case  ;  second,  the  re- 
sources of  the  patient  or  his  friends.  The  resources  may  be 
ample  and  suitable  in  every  respect,  but  the  nature  of  the 
case  may  be  such  that  there  is  only  one  course  open  to  you, 
and  that  is  asylum  treatment.  By  resources  is  not  here 
meant  merely  the  amount  of  money,  but  the  question  of 
accommodation,  the  position  of  the  house,  its  structural 
arrangement,  the  means  for  isolating  the  patient,  for  keeping 
him  under  supervision,  and  the  amount  of  scope  which  is 
possible  for  him  outside  the  house  altogether.  Of  course,  it 
goes  without  saying  that  money  is  an  important  element  in 
the  calculation,  for  the  treatment  of  an  insane  patient  in  a 
private  house  is  rather  expensive. 

If  it  is  an  acute  case,  two  attendants  or  nurses  may  be 
required — one  for  day,  and  one  for  night  duty,  or  even  more. 
The  amount  of  paid  attendance  will  be  determined  by  the 
extent  to  which  you  can  rely  on  the  judicious  assistance  that 
can  be  obtained  from  friends.  A  house  in  the  country,  if  it 
is  commodious  enough,  and  has  suitable  rooms,  is  for  an 
acute  case  very  much  better  than   any   residence  in  town, 

6 


82  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

although  many  cases  not  so  acute  in  character,  and  not  so 
deeply  deranged,  are  often  treated  successfully  in  populous 
centres.  You  must  always  bear  in  mind  the  possible  effect 
on  the  relatives  as  well  as  on  the  patient.  What  has  just 
been  said  applies  more  particularly  to  cases  where  the  attack 
is  recent,  and  where  there  is  naturally  strong  hope  of  recovery. 
It  may  be  too  soon  yet  to  attempt  a  prognosis,  and  if  private 
treatment  is  possible,  and  to  be  recommended  from  a  medical 
point  of  view,  it  averts  the  stigma  which,  unfortunately, 
attaches  too  much  to  asylum  treatment.  Many  cases  can 
be  treated  at  home  after  the  acute  stage  is  past,  and  when 
recovery  is  no  longer  possible,  for  the  risks  of  the  acute 
stage  have  disappeared,  and  home  care  and  supervision  are 
now  possible.  If  an  acutely  insane  patient  is  to  be  treated 
at  home,  or  in  some  other  private  house,  an  irksome  responsi- 
bility is  incurred  by  the  family  physician  if  he  undertakes 
the  case,  and  more  serious  than  is  incurred  when  the  patient 
is  sent  to  an  asylum. 

It  is  well  now  to  consider  what  cases  are  most  likel}'  to 
benefit  by  treatment  at  home,  and  what  ones  are  most  likely 
to  benefit  by  asylum  treatment.  My  experience  is,  strange 
though  it  may  seem,  that  acute  cases  of  mania  have  been 
more  successfully  treated  in  private  houses  than  cases  of 
melancholia.  The  acute  case  of  mania  is  often  more  or  less 
oblivious  to  his  position  and  surroundings.  He  sometimes 
does  take  advantage  of  his  relatives  and  friends,  who  are 
usually  too  indulgent  to  his  whims,  and  suspicions,  and 
violent  outbursts  ;  but  he  is  not  so  utterly  self-engrossed  as 
the  melancholic  patient,  and  the  treatment  which  can  be 
provided  in  a  private  house  where  the  means  are  available,  and 
under  the  charge  of  capable  attendants,  is  often  sufficient  to 
ensure  his  recovery,  especially  if  the  case  is  a  transient  one. 

For  the  melancholic,  except  mild  cases,  where  the  prog- 
nosis is  obviously  good  from  the  first,  I  am  disposed  to 
recommend  asylum  treatment  as  a  rule,  even  where  the 
financial  position  is  adequate.  If  treatment  must  be  resorted 
to  in  a  private  house,  let  it  be  a  private  house  which  is 
strange  to  the  patient,  and  let  the  servants  and  attendants 
be  strangers  also.     This  rule  applies  also  to  mania  and  to 


GENERAL  PRINCIPLES  OF  TREATMENT  83 

any  form  of  insanity,  with  a  few  exceptions,  which  need  not 
be  specially  referred  to,  as  no  two  cases  of  them  are  alike, 
and  they  will  be  obvious  when  they  do  occur.  There  must 
be  cases  where  a  strong  family  attachment,  the  nursing 
devotion  of  a  relative,  will  help  towards  the  cure  of  the 
patient  more  than  strangers.  These  cases  are  exceptions, 
and  must  be  judged  on  their  own  merits. 

To  treat  successfully  a  case  of  insanity  in  private  practice, 
certain  rules  should  be  kept  in  mind  :  First,  except  in  special 
cases  such  as  those  just  referred  to,  allow  no  interference  on 
the  part  of  a  friend.     I  remember  a  case  of  a  young  lady 
under  the  charge  of  two  nurses,  who  was  persistently  fed 
according  to  the  instructions  of  her  father  and  mother,  con- 
trary  to    the    doctor's    orders,    the    nurses    having   weakly 
succumbed  to  the   influence   of  the   parents.     Such   a  case 
should  never  have  been  treated  at  home,  although  she  might 
very  well  have  been  placed  in  a  house  away  from  the  influ- 
ence  of  her  relatives.     Second,   a   rule   of  importance   is  to 
secure    good    supervision    and    nursing,    and    therefore    the 
judicious   selection  of  attendants  is   a  primary  precaution. 
It  is  generally  found  that  those  who  have  had  asylum  train- 
ing are  much    more  reliable,  and  show  better   pluck  than 
those  who  have  no  experience  of  mental  nursing.     Third,  it 
should  be  the  doctor's  business  to  see  that  the  nurse   or 
attendant   is    not    overtaxed,    that    she   gets   enough   sleep, 
enough  recreation  and    exercise    in    the    open    air,   suitable 
food,  and  no  stimulants.     It  is  usually  necessary  to  have  a 
day  and  night  nurse  where  assistance  from  the  friends  is 
undesirable,  and  it  may  be  necessary  to  have  more.     Fourth, 
the   nurse  must  be  carefully  instructed  as  to  the  nature  of 
the  case,  its   probable  outcome,  the  risks,  such  as  suicide, 
homicide,  setting  fire  to  things,  and  so  forth.     She  should 
be    provided  with    a  note-book    and    temperature  chart,   in 
which  entries  should  be  made  as  to  the  diet,  state   of  the 
bowels,  pulse,  temperature,  mental  symptoms,  sleep,  exercise, 
etc.     Fifth,  all  possible  risks  should  be  minimized,  and  they 
are  greater  in  private  houses  than  in  asylums,  where  special 
precautions    are   taken,    and  special   structural   provision  is 
made.     Everything  such  as  knives,  razors,  weapons  of  any 

5 — 2 


84  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

description,  should  be  removed,  and  there  should  be  as  little 
furniture  in  the  room  as  possible.  Where  there  is  any  risk 
of  suicide,  the  room  should  be  on  the  ground-floor.  Sixth, 
the  patient's  weight  should  be  taken  in  an  acute  case  at 
intervals  of  three  days ;  when  less  acute,  at  intervals  of  a 
week  or  a  fortnight.  In  the  '  Hand-book  for  Attendants  on 
the  Insane  '  (published  by  Bailliere,  Tindall,  and  Cox),  there 
are  directions  given  to  nurses,  and  valuable  information 
regarding  the  treatment  of  the  insane  in  private  houses. 

It  may  be  well  now  to  inquire  into  the  usual  medical 
routine  of  asylum  treatment,  and  such  hints  as  can  be 
gleaned  and  prove  available  for  private  practice  will  be 
pointed  out  en  passant.  When  a  patient  is  admitted  to  an 
asylum,  one  of  the  medical  officers  receives  the  patient, 
hands  him  over  to  an  attendant  to  be  undressed  and  put 
to  bed  for  medical  examination,  and  while  this  is  being 
done,  interviews  the  friends  if  they  are  present,  and  obtains 
a  history  of  the  case.  The  history  comprises  physical  as  well 
as  mental  incidents,  and  consists  of  three  parts :  i.  Hereditary. 
2.  Personal,  from  time  of  birth  onwards  to  the  time  of  the 
mental  attack.  3.  Present  attack,  including  (a)  prodromata — 
change  of  manner,  habits  or  conduct,  sleeplessness;  (b)  mental 
development  of  attack,  the  symptoms  being  stated  in  the 
order  of  their  appearance ;  (c)  order  of  appearance  of  the 
physical  symptoms  —  appetite,  digestion,  state  of  bowels, 
micturition,  and  other  symptoms.  With  the  information 
now  obtained,  and  any  further  suggestions  from  friends,  the 
predisposing  and  exciting  causes  may  be  inferred,  if  not 
ascertained  with  certainty. 

The  medical  examination  is  similar  to  that  conducted  in 
the  wards  of  a  general  hospital,  only  that  nervous  and  mental 
symptom^s  are  invariably  looked  for  and  stated  as  fully  as 
possible.  Each  hospital  has  one  or  more  methods  of  case- 
taking,  with  which  students  are  familiar,  and  it  is  only 
necessary  here  to  limit  attention  to  the  mental  inquiry. 
The  following  system  may  be  adopted  : 

I.  Attention  and  Observation. — Can  the  attention  be  fixed? 
Is  it  so  only  temporarily  ?  Or  is  it  done  with  difliculty  ? 
Does  he  observe  what  is  done  in  his  presence  ?  - 


MEDICAL  EXAMINATION  TO  BEGIN   WITH  85 

2.  Apparent  Consciousness. — Some  patients,  indeed  most, 
are  more  or  less  conscious  of  what  is  passing  on  around 
them  ;  but  the  field  of  consciousness  is  more  or  less  narrowed 
with  many,  and  they  often  need  to  be  roused  before  there 
is  apparent  consciousness  at  all.  It  is  well  to  distinguish 
between  apparent  consciousness,  which  is  evident  at  first 
sight,  and  that  which  is  only  evident  on  being  roused.  I 
have  noticed  the  attention  roused,  thus  indicating  a  degree 
of  consciousness,  as  a  passing  glimpse  in  a  case  of  acute 
delirious  mania.  Many  have  been  conscious,  as  we  learn 
after  recovery  (melancholic  stupor),  w^ho  cannot  be  roused 
to  give  any  evidence  of  it  when  stupor  is  profound. 

3.  Can  he  answer  Questions  ? — Some  cannot,  perhaps  from 
paralysis  or  despair,  or  because  inhibited  by  an  imperative 
idea,  and  others  because  of  dementia  ;  but  many  fail  to 
answer  from  obstinacy,  suspicion,  or  pride. 

4.  Brightness  or  Dulness  of  Intellect. — If  the  patient  does 
not  speak,  and  the  expression  is  negative  or  clouded,  not 
much  information  can  be  elicited  here.  A  patient,  per- 
severing inquiry,  an  enticing  manner  and  tact,  are  very 
helpful  in  drawing  out  the  patient  frankly. 

5.  Speech. — Reticence  or  frankness.  The  vocabulary  of 
the  patient  can  be  tested,  and  the  motor  function  of  speech, 
whether  free  and  unrestrained,  or  halting,  tremulous,  stutter- 
ing, slurred,  or  more  or  less  paralyzed. 

6.  Coherence.  —  As  already  stated,  there  are  degrees  of 
incoherence,  and  a  man  may  be  coherent  and  yet  rambling 
in  his  statements. 

7.  Memory. — This  should  be  fully  tested,  and  the  following 
distinction  is  very  important :  {a)  of  recent  events ;  (6)  of 
older  events. 

8.  Expression.  —  It  may  be  obtuse,  suspicious,  happy, 
melancholy,  excited,  etc. 

9.  Exaltation. )  These   have  been  already  referred  to  as 

10.  Depression.  ]      diagnostic  characters. 

11.  Excitement — of  manner,  speech,  reminiscence,  religious, 
etc. 

12.  Delusions  and  their  Character. — Refer  to  previous  classi- 
fication. 


86  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

13.  Hallucinations  or  Illusions. — Specify  the  senses  involved. 

14.  Additional  Observations  as  to  habits  and  propensities 
(filthy,  destructive,  indecent,  etc.,  suicidal  or  homicidal 
tendencies).  Has  he  attempted  suicide  or  homicide,  or  has 
he  only  threatened  so  far  ? 

15.  The  Attitude  and  Gait  of  the  Patient. 

It  may  be  that  this  is  too  long  and  elaborate  a  system  for 
private  practice,  but  it  will  serve  as  a  guide,  and  much  that 
would  otherwise  escape  notice  is  in  this  way  brought  to 
light.  The  patient  is  examined  also  for  marks  of  injuries, 
skin  eruptions,  and  any  external  evidence  of  disease.  It  is 
most  important  to  do  so,  for,  just  as  in  the  excitement  of 
battle  wounds  are  unheeded,  in  the  excitement  and  distrac- 
tion of  mental  disease  injuries  may  occur  without  the  patient 
being  conscious  of  them,  and  to  overlook  the  fact  would  be 
a  serious  mistake. 

A  word  of  caution  may  be  here  given  with  reference  to 
the  physical  examination  of  internal  organs.  The  sensibility 
of  the  insane  is  often  diminished,  and  the  visceral  reflexes 
are  often  abolished,  or  nearly  so.  Thus,  a  patient  with 
phthisis  or  pneumonia  may  have  no  cough  or  spit,  and  the 
temperature  may  be  only  normal  or  slightly  above  it,  as  in 
a  recent  case  under  treatment,  where  the  stage  of  gray 
hepatization  of  the  right  lung  was  reached  in  a  female 
paralytic,  and  only  discovered  post-mortem. 

The  temperature  of  the  chronic  insane  is  usually  below 
par,  and  in  dements  the  thermometer  often  registers  as  low 
as  96° ;  but  in  acute  mania  it  is  above  normal,  though  not 
markedly  so,  and  in  general  paralysis,  in  post-convulsive 
and  apoplectic  states,  and  in  acute  physical  diseases  more 
or  less.  But,  as  already  stated,  there  may  be  exceptions  to 
the  last-mentioned  rule. 

The  patient  next  receives  a  cleansing  bath  ;  frequent 
cleansing  baths  are  most  helpful  in  preventing  undue  ob- 
struction of  the  excretory  channels,  and  pathological  obser- 
vation reveals  the  fact  that  in  the  brain  this  is  apt  to  occur 
where  there  is  persistent  afflux  of  blood  to  the  brain.  It  is 
a  usual  rule,  if  there  are  no  contra-indications,  to  prescribe 
opening  medicine  at  the  outset.     In  practice  it  is  found  to 


GENERAL  PRINCIPLES  OF  TREATMENT  87 

be  beneficial,  and  not  a  few  cases  are  relieved — of  at  least 
their  more  acute  symptoms — by  careful  attention  to  the 
skin,  kidneys,  and  bowels. 

If  the  patient  is  depressed,  or  has  threatened  or  attempted 
suicide,  or  suffers  from  commanding  hallucinations,  he  is 
placed  in  a  dormitory  under  special  observation.  If  acutely 
excited,  aggressive,  violent,  or  homicidal,  he  is  placed  in  a 
strong  side-room  with  observation  window  in  the  door,  or,  if 
need  be,  in  a  padded  room  ;  if  epileptic,  in  a  special  dormitory 
for  epileptics  ;  if  in  weak  health,  in  the  hospital.  In  private 
practice  there  is  little  or  no  choice ;  but  the  distribution 
above  described  suggests  various  considerations  to  be  kept 
in  view  in  the  disposal,  supervision,  and  care  of  the  patient. 

In  private  practice,  where  the  case  is  acute,  to  avoid  risk 
of  injury  to  the  patient  or  others  in  attendance,  what  is 
known  as  the  dry-pack  may  be  adopted,  and  for  surgical 
treatment  of  acute  cases  this  is  often  absolutely  necessary 
in  order  to  ensure  rest  to  the  diseased  or  injured  part.  The 
patient  is  enveloped,  hands  and  feet  included,  the  head  and 
neck  only  being  left  bare,  in  a  blanket  which  is  stitched 
from  the  feet  upwards ;  but  care  must  be  taken  not  to  re- 
strain the  thorax  and  abdomen  too  much,  and  to  release  the 
patient  and  sponge  the  whole  body,  for  cleansing  and  soothing 
reasons,  at  least  twice  in  twenty-four  hours.  This  dry-pack  is 
useful,  but  it  is  liable  to  be  abused,  and  the  nurse  should 
not  be  implicitly  trusted  as  to  its  use. 

Patients  have  been  known  to  die  in  the  dry-pack  for  want 
of  the  precautions  which  have  been  mentioned.  As  soon  as 
possible  it  ought  to  be  dispensed  with,  and  the  medical  man 
in  charge  of  the  case  should,  while  it  is  in  use,  see  that  there 
is  no  undue  restraint,  and  that  the  patient  is  cleansed  after 
evacuations,  and,  as  already  stated,  sponged  all  over  not  less 
than  twice  in  twenty-four  hours. 

The  wet-pack  is  frequently  used  in  some  asylums  for  acute 
maniacal  cases,  and  the  method  adopted  is  as  follows  :  Two 
pairs  of  blankets  are  laid  out  across  the  bed,  the  naked  body 
is  wrapped  in  a  sheet  wrung  out  of  water  of  a  temperature 
of  about  50°,  and  applied  so  as  to  envelop  the  limbs  entirely 
as  well  as  the  body.     The  blankets  are  then  wrapped  round 


88  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

the  patient,  enclosing  him  and  his  wet-pack,  and  he  may  be 
thus  kept  for  twenty  minutes  to  an  hour,  or  more  if  necessary; 
but  under  medical  supervision,  and  always  with  the  risk  of 
exhaustion  or  syncope  kept  in  view. 

Hydropathy  may  be  tried  by  other  means  in  like  cases,  such 
as  tepid  baths,  with  cold  to  the  head,  alternating  warm  and 
cold  douche,  or  the  Turkish  bath. 

Opinions  vary  as  to  the  efficacy  of  these  measures ;  but  in 
private  practice,  where  resources  are  few,  it  is  well  to  have 
them  in  mind,  and  in  critical  emergencies  they  may  prove 
serviceable. 


CHAPTER  VI. 

GENERAL  PRINCIPLES  OF  TREATMENT  {continued). 

Alimentation  —  Refusal  of  food  —  Forced  alimentation  —  Objections — 
Methods — Exercise— Sleep — Attention  to  bowels  and  urine  — Bed- 
sores— Danger  of  accidents — The  insane  ear — Menstruation — Rest 
in  bed — Travelling — Thyroid  treatment  — Classification. 

Alimentation. — The  feeding  of  the  patient  in  all  cases  of 
recent  or  acute  insanity  must  be  regarded  as  of  very  great 
importance.  He  may  take  his  food  readily  with  eager 
avidity,  with  impulsive  haste,  and  bolt  it  into  the  stomach 
imperfectly  masticated  and  devoid  of  salivary  digestion. 
This  is  quite  common  in  acute  maniacal  conditions,  but  the 
opposite  not  infrequently  happens,  and  the  patient  refuses 
food,  or  requires  to  be  coaxed,  and  eats  very  slowly  in  a 
dribbling,  inconsequent,  indifferent  manner.  Great  tact  is 
often  required  in  getting  insane  patients  to  take  their  food, 
and  it  ought  to  be  impressed  on  the  nurse  as  of  far  more 
consequence,  and  far  better  for  the  patient  that  the  food 
should  be  taken  without  compulsion,  because  its  digestion  is 
then  more  perfect  and  nutritious.  Much  depends  on  the 
manner  in  which  food  is  served.  If  it  is  palatable  and  has 
an  appetizing  odour,  if  it  is  presented  to  the  patient  on  a 
spotless  tray-cloth  with  all  the  accessories  bright  and  clean, 
it  is  more  likely  to  tempt  a  capricious  appetite  than  if  it  is 
served  rudely  and  oifensively.  It  is  well  to  bear  this  in 
mind,  for  the  insane  are  more  sensitive  than  one  might 
suppose,  and  because  many  patients  have  very  little  appetite, 
and  their  powers  of  digestion  are  below  par.  The  nature  of 
the  food  must  be  prescribed  by  the  medical  attendant.  If 
the  patient  is  epileptic  or  paralytic,  or  dysphagic,  it  must  be 


90  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

triturated  small,  and  liquefied,  so  as  to  permit  of  being  easily 
swallowed,  for  the  risks  of  choking  in  such  cases  are  con- 
siderable. For  patients  who  bolt  their  food  it  is  well  to 
have  it  chopped  fine  beforehand,  to  have  it  liquefied  also, 
and  to  have  the  patients  spoon-fed.  The  nurse  should 
receive  implicit  instructions  to  grudge  no  time  or  patience 
with  patients  who  linger  and  toy  over  their  meals,  for  the 
non-success  of  treatment  in  flaccid,  anorexic,  ansemic  cases 
is  often  due  to  the  abrupt  manner  and  careless  indifference 
of  the  nurse  who  presides  over  the  meals  of  such  patients. 

Absolute  refusal  of  food  adds  very  much  to  the  difficulties 
of  the  case.  In  some  instances  it  ma}^  be  a  misnomer  to 
speak  of  absolute  refusal  of  food.  There  may  be  no  resist- 
ance whatever,  a  mere  suspension  of  will-power,  and  the 
artificial  feeding  of  the  patient  may  be  the  easiest  thing  in 
the  world,  but  as  a  rule  there  is  more  or  less  positive  refusal 
of  food  where  forced  alimentation  is  called  for.  It  may  be 
simpl}'  due  to  want  of  appetite,  with  absence  of  any  sense  of 
duty  to  maintain  life.  This  want  of  appetite  may  be  the 
result  of  a  purely  atonic  condition,  or  of  some  grave  organic 
disease  of  the  alimentary  tract  or  relative  viscera,  or  any 
other  cause  likely  to  induce  anorexia.  It  may  be  due  to 
obstinacy  in  an  irritable  patient,  to  insane  pride  and  self- 
will.  The  usual  explanation,  however,  is  a  delusion  or 
hallucination,  or  suicidal  intention.  Delusions  accounting 
for  refusal  of  food  are  of  many  kinds,  and  only  a  few 
examples  need  be  cited.  These  are  the  delusions  that  the 
patient  has  no  stomach,  that  his  food  is  poisoned,  or  that  he 
has  no  money  to  pay  for  his  food.  He  may  be  under  the 
hallucination  that  God's  voice  commands  him  to  refuse 
food,  or  he  may,  of  determined  suicidal  purpose,  refuse  food 
in  order  that  he  may  die.  One  lady  refused  food,  being 
under  the  delusion  that  she  was  in  heaven  and  did  not 
require  food.  In  all  cases  persuasive  means  should  first  be 
tried,  for,  as  alread}'  indicated,  the  digestive  result  is  greater 
where  the  patient  chews  and  swallows  the  food  himself  than 
where  it  is  injected  directly  into  the  stomach. 

The  result  on  the  gastric  secretion  of  using  the  oral  or 
nasal  tubes  for  forced  alimentation  is  to  evade  the  operation 


GENERAL  PRINCIPLES  OF  TREATMENT  91 

of  a  physiological  process,  which  is  thus  described  by  Lauder 
Brunton  :  '  The  effects  of  mastication  are  not  limited  to  the 
changes  produced  by  it  in  the  food  within  the  buccal  cavity  ; 
the  taste  of  savoury  meat,  the  rolling  of  a  sweet  morsel  under 
the  tongue,  and  the  movements  of  mastication,  exert  an 
influence  upon  the  stomach  and  upon  the  brain.  In  a 
case  of  gastric  fistula,  where  the  oesophagus  was  occluded, 
Richet  noticed  that  the  mastication  of  food  induced  secre- 
tion of  gastric  juice,  although  nothing  could  pass  from  the 
mouth  into  the  stomach  on  account  of  the  obstruction  of 
the  gullet.'  At  a  later  stage  when  food  enters  the  stomach 
the  bile  and  pancreatic  secretions  are  called  forth  in  anticipa- 
tion of  the  exercise  of  their  respective  functions.  The  loss 
of  natural  stimuli  is  therefore  a  serious  objection  to  artificial 
feeding,  and  the  depressed  condition  of  the  reflex  functions, 
which  was  so  manifest  in  a  series  of  experimental  cases 
which  I  studied  some  years  ago,  proved  strongly  the  necessity 
for  natural  rather  than  artificial  feeding.  I  had  striking 
clinical  proof  of  this  also,  in  the  feeding  of  three  patients 
who  had  their  food  injected  four  times  a  day  for  seven  weeks, 
and  who  steadily  lost  weight,  although  the  struggling  was 
almost  nil.  Various  dietetic,  therapeutic,  stimulant  and 
digestive  combinations  had  been  tried,  the  cases  being  of  the 
most  asthenic,  unpromising  kind.  The  secretions  were 
altered  or  arrested,  the  mucous  lining  of  the  throat  relaxed 
and  irresponsive,  or  red,  irritable,  and  glutinous.  I  tried 
one  egg-custard  with  excess  of  milk,  two  egg-custards  with 
less  milk,  custards  with  brandy  and  custards  with  whisky, 
beef-tea  thickened  with  potato,  Benger's  liquor  pepticus 
and  liquor  pancreaticus,  Carnrick's  cod-liver-oil  emulsion, 
calomel,  acid,  and  nux  vomica,  bismuth,  and  washing  out 
the  stomach  with  Condy  or  carbolic.  The  pump  was  laid 
aside  at  last,  as  I  was  in  despair,  and  the  nurses  were 
instructed  to  spare  neither  time  nor  pains  to  tempt  and 
encourage  self-feeding  with  appetizing  and  dainty  morsels 
frequently  repeated.  The  sum  total  of  daily  ingesta  became 
thus  a  mere  fraction  of  that  daily  injected  for  seven  weeks  ; 
but  the  result  was  marvellous  and  gratifying  after  a  few 
weeks,  and  in  endeavouring  to  account  for  it,  I  remembered 


92  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

the  statement  of  Lauder  Brunton  and  the  observations  of 
Richet. 

The  explanation  of  the  change  is  quite  apart  from  the 
absence  of  any  physical  or  moral  effect  of  the  stomach-tube, 
which  in  my  practice  is  very  immaterial,  as  after  a  very 
considerable  experience  and  study  of  the  modus  operandi,  the 
time  occupied,  from  the  moment  when  the  patient  is  placed 
in  position  to  the  moment  when  the  tube  is  removed  and  the 
gag  withdrawn,  is  forty  seconds  at  the  outside.  I  have  fed 
in  this  way  several  thousand  times,  and  have  frequently 
timed  the  operation.  It  is  the  least  exhausting  feeding 
process  I  know  of,  and  is  so  rapid  that  ejection  of  the  food 
is  rarely  effected.  It  must  be  understood,  however,  that,  for 
the  physiological  and  clinical  reasons  already  stated,  I  dis- 
courage it,  if  it  can  possibly  be  avoided,  where  digestion  is 
seriously  impaired. 

If  forced  feeding  is  inevitable,  three  methods  are  open  to 
us  :  (i)  by  the  nasal  tube,  (2)  by  the  oesophageal  tube,  or  (3)  by 
rectal  injection.  The  nasal  tube  is  preferred  by  some  because 
of  the  difficulty  at  times  of  getting  the  jaws  parted  where  the 
patient  has  a  complete  set  of  good  teeth,  but  in  thickened 
conditions  of  the  mucous  membrane  of  the  nares,  or  where 
the  passages  are  narrowed  or  twisted,  the  insertion  of  the 
tube  may  be  attended  by  more  or  less  haemorrhage,  and  the 
act  of  respiration,  together  with  the  chances  of  the  tube 
bending  forwards  from  the  pharyngeal  wall,  may  send  it  into 
the  mouth.  In  using  it,  one  is  very  much  in  the  dark  as  to 
whereabouts  the  inner  end  of  the  tube  really  is  when  a  con- 
siderable length  of  it  has  disappeared  from  view.  I  have 
rarely  met  with  a  case  where  feeding  by  oesophageal  tube 
was  impossible,  and  the  risks  are  infinitesimal.  A  Ferguson 
gag  is  the  best  to  use  if  there  is  any  gap  between  the  jaws 
due  to  loss  of  teeth,  and  where  there  is  no  gap,  and  a 
difficulty  exists  in  introducing  the  Ferguson  gag,  the  old 
screw  gag  can  first  be  introduced,  and,  when  the  jaws  are 
slightly  separated,  the  Ferguson  gag  will  do  the  rest.  The 
advantages  of  the  Ferguson  gag  are  speed  and  good  leverage. 
A  soft  tube  is  what  is  usually  employed,  and  the  only  dif- 
ficulty    likely    to    be    encountered    in    passing    it    is    if  the 


GENERAL  PRINCIPLES  OF  TREATMENT  93 

passages  are  congested  and  the  mucous  secretion  is  thick  and 
glutinous,  or  where  the  patient  possesses  the  power  of  twist- 
ing the  tube  back  into  the  mouth,  and  some  are  very  clever 
in  wrestling  with  it  and  ejecting  it.  A  little  patience  will 
usually  be  attended  with  success.  The  food  ma}'  be  injected 
by  means  of  an  ordinary  stomach-pump,  or  by  means  of  a 
receptacle  placed  above  the  level  of  the  head  such  as  is  used 
if  washing  out  the  stomach  is  resorted  to.  For  rectal  injec- 
tion the  ordinary  enema  syringe  is  all  that  is  required.  The 
food  prescribed  in  all  such  cases  is  necessarily  of  a  liquid 
character,  and  the  favourite  custom  is  to  give  milk-and-eggs, 
one  or  two  eggs  being  beat  up  with  three-quarters  of  a  pint 
of  milk.  To  this  may  be  added  finely-grated  biscuit  so  as  to 
furnish  a  complete  physiological  diet,  and  it  may  be  alter- 
nated with  injections  of  thickened  beef-tea  or  soup.  The 
best  position  to  put  the  patient  in,  preliminary  to  artificial 
feeding,  is  between  the  legs  of  a  man  sitting  in  a  chair,  the 
arms  of  the  patient  being  wound  round  the  man's  legs,  and. 
held  each  by  an  attendant.  If  he  is  very  obstreperous,  one 
or  two  more  attendants  may  be  required.  This  forced 
alimentation  should  not  occupy  more  than  one  minute  if  the 
tube  is  easily  introduced,  and  certainly  not  more  than  two  or 
three  minutes  at  most.  The  diet  of  the  insane  should,  as  a 
general  rule,  be  of  a  non-stimulating  character,  except  when 
there  is  possible  exhaustion  and  a  tendency  to  collapse. 
Clouston  believes  largely  in  milk  and  egg  custards,  beef-tea, 
soups,  and  fattening  diet  generally,  and  his  practice  in  this 
respect  is  generally  approved  by  other  authorities.  If  any- 
thing, his  fattening  diet  is  sometimes  too  strong  for  the 
average  digestion,  and  the  proportion  of  eggs  which  he 
recommends  is  too  much. 

In  a  series  of  experimental  researches  which  I  made  some 
years  ago  on  the  diet  of  the  insane,  I  found  that  the  propor- 
tion of  eggs  to  milk  which  was  most  easily  digested  and  was 
attended  by  the  greatest  increase  in  weight  was  one  egg  to 
seven  ounces  of  milk,  and  that  where  the  proportion  of  eggs 
was  greater,  digestion  was  unable  to  cope  with  it,  and  a  loss 
of  weight  ensued.  It  was  found  also  that  rum  in  conjunc- 
tion with  these  liquid  custards  was  better  than  either  whisky 


94  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

or  brandy,  brandy  being  the  least  stimulating  and  nutritive 
of  the  three.  In  young  patients,  in  patients  who  masturbate, 
and  in  acute  cases  generally,  the  diet  should  not  be  unduly 
stimulating,  albuminous  food  should  be  restricted,  milk, 
farinaceous  food  and  fish  should  occupy  a  conspicuous  place, 
and  beef-tea,  because  of  its  mild  stimulation  and  its  action 
on  the  kidney  and  bowels,  should  frequently  be  administered. 
In  some  cases,  oxalates  are  freely  distributed  in  the  urine, 
notably  in  melancholies  and  masturbators,  and  vegetable 
diet  and  fruits  should  for  them  be  restricted.  In  old  cases, 
and  in  all  whose  bodily  health  and  vigour  is  below  par, 
stimulating  diet  of  a  digestible  kind,  and  even  stimulants, 
may  be  indicated. 

Exercise. — Muscular  activity  is  an  essential  condition  of 
the  successful  treatment  of  recent  and  acute  cases.  The 
excited  patient  cannot  sit  still.  There  is  muscular  unrest 
all  the  time,  and  this  of  itself  gives  us  an  indication  that  an 
increase  of  muscular  activities  will  relieve  the  mental  tension 
and  direct  a  safe  outlet  in  a  physiological  direction.  The 
melancholic  is  often  silent,  idle,  listless,  and  his  muscular 
energy  is  at  a  low  ebb.  His  self-absorption  paralyzes  all  his 
energies,  and  muscular  relief  is  the  very  best  thing  for  him. 
In  both  these  cases  the  muscular  work  done  should  be 
appreciable.  In  the  melancholic  mere  automatic  exercise 
does  not  prevent  his  following  the  morbid  train  of  thought. 
In  the  acute  case,  it  does  not  sufficiently  relieve  the  mental 
tension,  and  the  more  active  the  work  in  the  latter  case,  and 
the  more  engrossing  in  the  former,  the  better  for  the  patient. 
The  employment  of  the  insane,  no  matter  if  its  intrinsic  value 
is  nil,  is  one  of  the  best  means  of  treatment  which  has  yet 
been  discovered.  As  a  rule,  it  is  more  easy  to  find  employ- 
ment for  men  than  for  women,  especially  in  farm  and  garden 
work ;  but  for  women,  kitchen,  laundry,  and  house  work  are 
much  better  than  sewing  or  knitting,  because  the  employ- 
ment is  more  active  and  more  diverting.  Where  the  patient 
is  well  employed,  sleep  is  more  easily  obtained,  the  appetite 
is  stimulated,  digestion  is  more  perfect,  and  the  restoration 
of  the  patient  is  more  likely  to  be  ensured. 

Sleep. — In   the   progress  of   an   acute   case  with    sleepless 


GENERAL  PRINCIPLES  OF  TREATMENT  95 

nights  as  well  as  days,  exhaustion  will  ultimately  supervene, 
and  probably  death  ensue,  if  sleep  is  not  secured.  As  already 
stated,  active  muscular  exercise  tends  to  favour  sleep  ;  the 
patient  should  live  in  the  open  air  as  much  as  possible,  and 
while  there  is  any  hope  of  recovery,  narcotic  drugs  should  be 
sparingly  resorted  to.  I  have  known  a  case  of  acute  excite- 
ment, which  tried,  exhausted,  and  disheartened  the  attendants 
after  weeks  of  continuous  strain,  procure  his  first  sound 
refreshing  sleep  after  a  walk  of  twelve  miles,  and  a  not  too 
copious  supper  of  oatmeal  porridge  afterwards.  In  some 
cases  a  tepid  bath  favours  sleep ;  in  some  a  hot  bath  has  this 
result.  If  the  head  is  hot,  apply  cold  cloths  to  the  head, 
and  for  other  indications  attend  to  the  general  directions 
given  in  the  third  chapter  of  this  book.  Where  the  case  is 
getting  more  serious,  sulphonal  may  be  employed,  a  hypo- 
dermic injection  of  hypobromate  of  hyoscine,  or  some  other 
of  the  drugs  or  combinations  already  mentioned,  according 
to  individual  requirements.  There  should  be  the  most 
perfect  quiet  in  and  around  the  patient's  bedroom,  because 
in  many  acute  cases  sensation  is  excited  by  the  very  slightest 
stimulus,  and  the  faintest  creaking  of  a  hinge,  or  rasping  of 
a  lock,  or  noise  of  a  footstep,  is  sufficient  to  rouse  again  into 
wild  activity  the  excitem.ent  of  a  patient  just  dropping  off  to 
sleep.  In  melancholic  cases,  narcotic  drugs  may  do  less 
harm  unless  pushed  continuously  ;  but  their  effect  on  the 
primcB  vice  and  secretions  must  be  carefully  considered,  and 
the  risk  of  engendering  a  morbid  craving  must  not  be  over- 
looked. For  reduced  and  melancholic  cases  porter  or  beer 
are  often  very  serviceable,  and,  with  something  solid  at  bed- 
time, often  produce  a  soothing  effect,  and  may  promote  sleep. 
Bowels  and  Urine. — Attention  has  already  been  directed  to 
the  bowels,  and  it  may  seem  as  if  too  much  were  being  said 
on  the  subject.  It  is  only  necessary  now  to  add  that  there 
may  be  a  difficulty  in  getting  the  patient  to  take  laxative 
medicine.  He  may  object  to  castor-oil,  to  salts,  to  pills  or 
powders,  or  he  may  absolutely  refuse  them.  In  some  cases 
regular  attention  by  daily  enemata  prevents  the  patient 
soiling  his  clothes  or  passing  his  urine  and  faeces  in  bed. 
This  care  is  most  necessary  in  old  and  feeble  cases,  and  it  is 


96  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

most  useful  in  assisting  in  the  prevention  of  bed-sores.  For 
the  patients  who  require  a  sharp  purge,  and  who  absolutely 
refuse  medicine  of  any  kind  and  resist  enemata,  it  will  be 
found  that  a  drop  or  two  of  fresh  croton-oil  on  a  piece  of 
lump  sugar  dropped  into  tea,  or  some  other  liquid,  may  be 
taken  without  suspicion,  and  you  ma}'  be  amused  but  not 
surprised,  though  the  patient  is  next  day,  when  he  tells  you 
that  he  has  had  a  bad  attack  of  diarrhoea.  If  he  refuses 
food  as  well  as  medicine,  the  medicine  will  require  to  be 
introduced  with  milk  or  custard  by  the  stomach-tube.  Only 
less  important  than  attention  to  the  bowels  is  the  observa- 
tion of  the  state  of  the  kidneys  and  bladder,  and  the  con- 
dition of  the  urine.  I  have  known  a  patient  die  of  ursemic 
poisoning  because  his  bladder  was  distended  for  days  with- 
out any  suspicion  of  the  true  facts  of  the  case,  although  he 
had  not  passed  a  single  drop  of  urine.  It  must  therefore  be 
emphasized  again  that  insane  patients  differ  clinically  from 
sane  patients.  Apart  altogether  from  the  mental  symptoms 
which  distract  attention,  there  is  often  more  or  less  suspen- 
sion of  nervous  activity,  a  stuporose  indifference  to  the  calls 
of  nature,  and  in  medical  inquiries  nothing  '  matter  of  course  ' 
should  be  taken  for  granted. 

Setons  and  Blisters. — These  are  much  less  in  vogue  at  the 
present  time  ;  but  undoubtedly  cases,  if  properly  selected, 
derive  benefit  from  this  treatment.  They  are  of  no  value  in 
states  of  acute  excitement,  and  great  harm  is  done  by  their 
application  in  weak  anaemic  states.  Their  success  is  most 
assured  with  cases  of  anergic  stupor,  and  especially  that 
form  that  follows  acute  mania,  and  threatens  to  become 
chronic.  I  prefer  to  use  blistering  fluid  applied  lightly,  and 
repeated  from  time  to  time  so  as  to  keep  up  counter-irrita- 
tion for  a  considerable  time.  A  part  of  the  head  may  be 
shaved  at  one  time,  another  part  later,  and  so  on  till  the 
whole  scalp  and  nape  of  neck  have  been  gone  over. 

Bed-sores. — It  is  very  important  in  all  cases  of  long  con- 
finement to  bed  in  weak,  emaciated  patients,  and  in  patients 
suffering  from  organic  nervous  disease,  to  be  on  the  look- 
out for  bed-sores.  It  is  generally  held  that  most  bed-sores 
are  preventable ;  but  it  is  true  that  some  are  absolutel}^ 
unpreventable,  because  they  are  due  to  atrophic  conditions. 


GENERAL  PRINCIPLES  OF  TREATMENT  97 

They  are  simply  local  gangrenes,  and  may  make  their 
appearance  in  less  than  twenty-four  hours,  even  where  every 
precaution  has  been  taken.  It  is,  however,  the  duty  of  the 
nurse  to  see  that  the  bedclothes  are  smooth,  that  there  is  no 
crumpling  of  the  sheets,  no  crumbs  in  bed,  that  the  patient 
is  kept  dry,  and,  if  possible,  that  the  bed  is  a  spring  mattress 
or  a  water-bed.  If  there  is  a  difficulty  in  keeping  the  patient 
dry,  it  may  be  necessary  to  use  a  catheter  regularly,  or  an 
indiarubber  receptacle  if  the  patient  lies  quietly  in  bed.  A 
very  useful  prescription  for  patients  who  wet  their  beds, 
when  the  condition  is  probably  muscular  atony  of  the  bladder, 
is  15  drops  of  liquid  extract  of  ergot  and  15  grains  of  borax 
three  or  four  times  a  day.  If  it  is  to  be  long  continued,  nux 
vomica  may  be  substituted  for  the  ergot  for  a  time. 

Danger  of  Accidents. — Accidents  are  more  common  among 
the  insane,  and  are  due  to  falls,  struggles,  or  homicidal  and 
suicidal  attempts,  and  also  to  the  more  fragile  condition  of 
the  bones  in  some  of  the  insane,  notably  paralytics  and  senile 
cases.  In  the  case  of  old  people,  the  bed  should  be  on  the 
floor,  and,  if  possible,  the  floor  of  the  room  should  be  padded 
with  straw  mattresses,  as  these  patients  are  very  easily  injured, 
and  ecchymosis  appears  on  the  most  trivial  provocation. 

The  Insane  Ear  is  a  condition  of  the  ear  known  as  hcEuiatoma 
atcris,  which  occasionally  occurs  in  asylums,  and  consists  in 
an  effusion  of  blood,  which  is  now  believed  to  be  the  result 
of  a  degenerative  process  in  the  cartilage  cells,  and  the 
giving  way  of  new  vessels  of  defective  formation.  Rupture 
is  therefore  very  easy,  and  a  very  slight  blow  in  such  cases 
is  sufficient  to  produce  a  large  haemorrhage,  giving  the  ear 
a  swollen  appearance  the  shape  of  an  egg,  if  a  large  portion 
of  the  organ  is  involved.  This  condition  may  arise  without 
any  external  cause  whatever,  and  is  not  confined  to  the 
insane,  being  found  sometimes  among  athletes  and  prize- 
fighters. It  used  to  be  regarded  as  a  feature  of  bad  omen 
in  cases  of  insanity ;  but  there  are  many  cases  on  record  of 
recovery  after  its  appearance.  It  is  nevertheless  a  sign  of 
grave  import  in  some  cases,  and  where  the  prognosis  has 
been  reserved,  because  of  other  grave  sj^mptoms,  this  new 
feature  is  usually  conclusive.     I  have  had  cases  of  puerperal 

7 


98  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

insanity  recover  with  it,  and  also  cases  of  acute  mania. 
When  it  first  shows  itself,  the  skin  over  the  swelling  has 
usually  a  glazed,  bluish  appearance,  suggesting  a  blister,  and 
the  immediate  application  of  liquor  epispasticus,  not  too 
thickly  painted,  and  occasionally  repeated^ — every  other  day 
or  every  third  day — will  prevent  the  ear  from  being  per- 
manently deformed. 

Menstruation. — In  the  case  of  female  patients,  inquiries 
regarding  the  menstrual  flux  should  always  be  made.  At 
this  period,  usually  just  before  it,  the  mental  disease  often 
undergoes  a  change :  it  may  be  temporarily,  or  it  may  be 
critical  and  significant.  Sometimes  the  patient  is  worse 
after  or  during  the  menstrual  flow ;  but  in  any  case  it 
appears  to  have  an  influence  on  the  current  of  the  disease, 
and  inquiry  should  always  be  made,  especially  if  there  is 
anything  dubious  about  the  case. 

Rest  in  Bed. — It  is  sometimes  found  in  asylums,  and  the 
same  will  probably  be  found  in  private  practice,  that  certain 
patients  are  the  better  for  a  few  days  in  bed  now  and  again, 
especially  patients  of  the  more  chronic  class,  and  those  par- 
ticularly who  are  subject  to  recurrent  attacks  of  excitement. 
They  sometimes  feel  the  attack  coming  on,  or  are  in  dread 
themselves  of  a  recurrence,  and  I  have  often  found  such 
patients  taking  to  bed  voluntarily,  and  an  attack  become 
thus  prevented,  or,  at  any  rate,  reduced  in  severity. 

Travelling. — Travelling  is  a  favourite  remedy  often  sug- 
gested by  the  friends  of  patients,  or  by  the  patients  them- 
selves, for  the  treatment  of  mental  disease,  especially  at  the 
outset  of  an  attack.  It  is  of  no  value  in  acute  cases  ;  in 
fact,  it  is  attended  with  great  risk.  In  the  case  of  melan- 
cholies it  is  also  attended  with  risk,  but  if  careful  super- 
vision can  be  exercised,  and  the  mental  depression  is  of  a 
mild,  non-obtrusive  form,  there  is  more  prospect  of  its  doing 
good,  especially  if  the  tour  projected  is  one  full  of  interest 
and  likely  to  distract  the  attention  of  the  patient  from 
morbid  brooding.  During  convalescence  travelling  is  often 
resorted  to,  and  is  very  beneficial  in  promoting  and  establish- 
ing restoration,  but  every  case  should  be  judged  on  its  merits, 
as  too  much  travelling  may  be  exciting,  only  a  change  of 
residence  to  another  place  being  all  that  may  be  required. 


CLASSIFICATION  99 


Quite  recently  thyroid  extract  has  been  introduced  in  the 
treatment  of  insanity  by  Dr.  Macphail,  Derby,  and  Dr.  Bruce, 
of  Morningside.  At  first  the  new  treatment  appeared  to  be 
attended  with  most  encouraging  success,  but  it  has  not  con- 
firmed the  expectations  entertained  of  it.  It  is  well  known 
that  intercurrent  bodily  diseases  which  are  attended  by  much 
febrile  disturbance  often  occasion  a  glimmering  of  mental 
brightness  in  the  insane,  and  may  even  be  followed  by  mental 
recovery.  Thyroid  in  large  doses  induces  an  artificial  con- 
stitutional disturbance,  with  rise  of  pulse  and  fever,  and  it  is 
still  held  at  Morningside  that  undoubted  recoveries  have 
been  effected  by  this  treatment.  I  have  with  my  assistant 
colleagues  tried  it  very  thoroughly,  and  pushed  its  use  almost 
to  extremes,  and  while  still  hopeful  that  with  other  combi- 
nations some  good  results  may  be  obtained,  we  all  have  to 
confess  that,  except  in  a  case  of  myxcedema,  there  has  not 
happened  a  case  of  recovery  that  can  fairly  be  attributed  to 
thyroid  treatment. 

Classification. — Classification,  like  definition,  is  a  very  un- 
profitable occupation,  and  many  fruitless  labours  have  been 
expended  in  trying  to  reduce  the  manifestations  of  insanity 
to  a  systematic  arrangement,  which  explains  everything  and 
leaves  out  nothing.  The  oldest  arrangement  was  that 
founded  purely  on  symptoms,  and  originally  we  only  had  to 
deal  with  mania,  melancholia,  and  dementia.  This  obviously 
was  not  enough,  and  various  other  classifications  have  been 
adopted  and  more  or  less  rejected.  While  much  good  work 
has  of  late  years  been  done  in  elucidating  the  clinical  features 
of  mental  disease,  in  analyzing  groups  which  appear  to  have  a 
comrnon  origin  and  character,  and — as  the  result  of  analysis 
— in  resolving  these  groups  into  lesser,  more  distinct,  and 
separable  sub-groups,  the  time  is  not  ripe  for  a  classification 
that  will  meet  every  requirement,  and  give  an  intelligible 
bird's-eye  view  of  the  whole.  It  is  therefore  proposed  here 
to  take  up  first  of  all  the  old  symptomatological  group, 
and  from  that  starting-point  proceed  to  differentiate  further, 
so  that  we  may  regard  insanity  from  several  points  of  view 
and  have  more  concrete  ideas  of  the  subject.  No  apology 
will  here  be  made  for  arranging  together  what  is  believed  to 

7—2 


loo  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

be  the  best  of  examples  of  all  the  classifications  which  have 
hitherto  appeared.  What  is  aimed  at  is  the  labelling  of 
every  case  which  comes  before  you  with  a  name,  albeit  the 
name  may  not  be  quite  so  appropriate  as  an  exacting 
scientific  nomenclature  would  demand.  It  is  quite  true 
that  the  first  group,  the  symptomatological,  if  sufficiently 
divided  and  subdivided,  will  embrace  all  forms  of  insanity, 
but  the  elaboration  of  this  implies  the  addition  of  qualifying 
terms  which  introduce  new  phases  in  the  description  of  the 
disease,  and  multiply  its  features  and  relationships.  The 
term  'mania'  may  be  qualified  by  the  word  'puerperal,' 
which  lifts  it  out  of  a  general  category  and  gives  a  specific 
distinction  to  the  case,  and  the  same  may  be  said  of  epileptic 
mania  and  other  forms  of  insanity.  In  spite  of  all  the 
objections  that  have  been  alleged  against  the  terminology  of 
mental  disease  which  has  obtained  for  several  years,  there 
can  be  no  doubt  of  its  helpfulness,  if  not  carried  too  far,  and 
if  founded  on  facts  which  enable  us  clearly  to  distinguish 
one  case  from  another.  A  wide  grasp  of  symptomatological 
types  is,  of  course,  of  fundamental  importance,  and  if  we  can 
differentiate  any  of  them,  e.g.,  chronic  delusional  insanity 
of  systematic  evolution,  so  clearly  as  to  make  respiration 
easy  and  undoubted  without  trenching  on  an}'  other  classifi- 
cation, so  much  the  simpler  and  better.  The  arrangement 
which  will  be  adopted  in  the  following  pages  has  been  found 
intelligible  and  useful,  and  it  takes  in  nearl}'  all  the  cases 
that  are  likely  to  be  met  with.  The  exception  may  be  made 
that  insanit}"  appears,  apart  from  causes  and  conditions  which 
denote  a  particular  type,  and  at  ages  between  the  critical 
epochs  of  life,  which  cannot  be  referred  to  any  type  but  the 
S3'mptomatological,  which  becomes  then  the  refuse-heap  of  all 
the  other  types,  because  its  meshes  are  wide  enough  to  receive 
what  the}'  reject.  But  if. this  all-embracing  group  can  give 
it  a  place  as  a  definite,  orderly,  and  distinguishable  array  of 
symptoms,  and  finally  fix  its  position  in  the  classification, 
there  is  no  need  for  further  refinement.  Thus  chronic  de- 
lusional insanity  of  systematic  evolution,  epileptic  insanity, 
and  general  paralysis  are  found  in  the  symptomatological 
group,  their  first  and  final  resting-place; 


CHAPTER  VII. 

MELANCHOLIA— KATATONIA— CATALEPSY. 

Many  of  the  so-called  insane  are  only  partially  afifected — Alterations  of 
consciousness — Classification  of  forms  according  to  symptoms  : 
Melancholia, mania,  dementia, stupor — Melancholia, varieties:  simple, 
neuralgic,  acute,  delusional,  hypochondriacal,  resistive,  silent,  chronic, 
senile,  melancholia  with  stupor — Katatonia — Catalepsy — /Etiology 
— Diagnosis — Prognosis — Treatment — Clinical  Illustrations. 

The  more  intimately  we  become  acquainted  with  the  various 
phases  of  insanity,  the  more  we  will  see  for  ourselves  that 
they  are  in  a  great  many  cases  phases  of  minds  which  in 
large  measure  still  retain  their  original  attributes  and  acquire- 
ments of  education  and  experience.  Many  of  the  insane  are 
not  so  very  different  from  ourselves,  after  all.  The  first  case 
you  meet  may  be  a  mason  who  is  subject  to  delusions  of 
persecution,  who  believes  that  the  thoughts  of  his  mind  are 
read  by  others,  and  that  he  is  restrained  in  his  movements 
by  unseen  agencies.  Discuss  with  him  the  plan  and  con- 
struction of  a  house,  and  he  will  discourse  with  the  intelli- 
gence which  comes  from  experience  regarding  the  workman- 
ship, the  plumb  of  a  wall,  the  dressing  of  the  stone,  and  the 
stability  of  the  structure.  He  is  still  able  to  engage  in 
general  conversation  apart  from  his  delusions,  and  his 
memory  and  knowledge  in  certain  directions  is  probably 
better  than  your  own.  We  have  therefore  to  regard  insanity 
— always  providing  for  exceptions,  however  —  as  being  a 
partial  occlusion  or  perversion  of  one  or  more  of  the  mental 
faculties,  and  a  limitation  of  the  field  of  consciousness  with 
•or  without  intensity  in  certain  directions. 

If  we  select  at  random  any  ten  patients  in  an  asylum, 
we  will  note  that  they  are  not  all  equally  responsive,  nor  do 
they  appear  to  be  equally  conscious  and  alive  to  their  environ- 


I02  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

ment.  In  a  less  degree  we  find  this  difference  outside  of 
asylums.  Some  men  observe  everything,  others  are  more 
in  a  state  of  abstraction  and  unconsciousness  of  outward 
affairs.  Consciousness  of  self  also  varies,  and  especially 
among  the  insane  you  will  find  many  differences  in  this 
respect.  At  one  extreme  is  the  melancholic  or  the  hypo- 
chondriac, at  the  other  the  dement,  and  flitting  between  is 
the  maniac,  who  may  be  self-conscious  in  one  sense,  and  not 
in  another.  The  insane  phases  of  character  and  conduct 
are  in  proportion  to  the  degree  of  occlusion  of  consciousness 
in  any  direction,  or  the  degree  of  its  vividness  in  another. 

Consciousness  may  be  perverted,  as  when  a  man's  identity 
of  himself,  his  friends  and  surroundings,  is  altered,  as  in 
acute  mania.  We  do  not  say  it  is  lost,  for  he  has  still  con- 
sciousness of  a  kind,  though  he  is  carried  away  from  the 
realism  of  his  former  everyday  life,  and  lives  among  imagina- 
tions, shadowy  myths  as  we  regard  them,  and  is  oblivious  to 
the  calls  of  nature  and  the  solicitations  of  those  around 
him.  He  may  be  sufficiently  conscious  to  recognise  some 
by  name,  and  not  others,  who  are  perhaps  not  so  well 
known,  to  thread  his  way  through  the  house  and  find  some- 
thing to  eat,  or  to  walk  over  a  bridge  instead  of  trying 
to  fly  over  it.  Not  long  ago  I  was  consulted  regarding  a 
gentleman  who  was  able  to  answer  questions  correctly, 
recognised  his  brother  who  was  with  him,  and  followed  his 
brother's  guidance  from  cab  to  station,  into  the  train,  and 
out  of  it,  and  then,  being  taken  by  the  hand  at  an  un- 
accustomed station,  turned  round  suddenly,  and  fired  a 
torrent  of  abuse  on  this  same  brother,  whom  he  regarded  as 
a  stranger,  and  with  whom  he  refused  to  go.  A  few  minutes 
after  he  looked  as  if  coming  out  of  a  dream,  and  said,  '  Jack, 
that  was  funny  !  do  you  know  I  didn't  recognise  you  as  my 
brother  just  now.' 

In  considering  insanity  of  different  kinds,  we  will  do  well  to 
settle  this  question  :  How  far  is  the  patient  conscious  of  his 
real  environment  and  his  real  self  ?  and  the  result  will  deter- 
mine whether  we  should  call  the  case  melancholia,  mania, 
dementia,  or  stupor.  In  melancholia  consciousness  is  not 
lost  ;  in  regard  to  self  it  is  intensified,  in  regard  to  the  environ- 


MELANCHOLIA  103 


ment  it  may  be  limited  or  it  may  not.  In  mania  it  may  be 
merely  restricted,  but  in  acute  mania  it  is  altered,  the  man's 
identity  and  the  identity  of  his  surroundings  being  more  or 
less  lost,  and  insane  imaginations  having  taken  their  place. 
In  dementia  it  is  diminished,  and  in  stupor  more  or  less 
suspended.  I  have  just  indicated  the  four  clinical  groups  of 
the  symptomatic  classification :  melancholia,  mania,  dementia 
and  stupor.  Melancholia  and  mania  in  their  typical  characters 
are  two  extremes,  the  one  the  extreme  pole  of  the  other.  In 
melancholia  the  prevailing  note  is  a  wail ;  in  mania  it  is  noisy, 
often  violent  excitement,  and  may  be  attended  with  exalta- 
tion, and  always  without  grief. 

Melancholia  is  sometimes  described  as  a  subjective  state. 
As  its  name  implies,  it  is  a  state  of  depressed  painful  feeling. 
The  patient  is  intensely  self-conscious,  introspective,  and 
harrows  his  feelings  with  an  insane  persistency  that  suggests 
in  some  cases  a  selfish  gratification.  The  origin  of  the  word 
melancholy  is  /jieXa^;  %oA.?7,  '  black  bile,'  and  knowing  how  much 
the  state  of  the  liver  influences  the  consciousness  of  the  sane, 
this  derivation  is  not  surprising.  Melancholia  is  a  morbid 
state  beyond  the  melancholy  or  depression  which  are  more 
or  less  common  in  everyday  life.  Its  duration  and  intensity 
vary  even  within  normal  limits,  but  it  may  become  so  pro- 
nounced without  intellectual  distortion  as  to  come  within 
the  category  of  insanity,  and  it  is  then  regarded  as  the 
simplest,  most  uncomplicated  form,  and  known  as  (i)  Simple 
Melancholia.  Patients  of  this  class  are  sometimes  voluntary 
boarders  in  asylums.  They  are  purely  subjective,  their 
minds  in  all  other  respects  are  normal.  There  is  no  morbid 
weariness  of  life,  no  suicidal  promptings,  no  insane  thoughts 
or  actions,  and  the  patient  cannot  be  certified  insane  on  the 
strength  of  this  symptom  alone,  for  a  document  cannot 
convey  to  a.  judicial  authority  the  whole  truth,  as  would  a 
medical  examination.  George  Eliot  suffered  at  times  acutely 
from  headache  and  mental  depression,  and  her  emotional 
existence  was  clouded  at  such  times  ;  but  her  great  intellectual 
gifts,  though  suspended  in  their  activities  under  the  para- 
lyzing spell  of  nervous  agony  and  emotional  depression,  were 
only  temporarily  in  abeyance.     Such  recurrent  attacks,  how- 


I04  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

ever,  were  but  a  remove  from  that  state  of  mind  which 
raises  the  question,  Is  hfe  worth  hving  ?  and  a  condition 
which  may  be  called  (2)  neuralgic  or  congestive  melancholia, 
which  is  a  distinct  form  of  depression,  and  associated  with  a 
highly  nervous,  sensitive,  neuralgic  organization,  and  a  long- 
ing for  relief  so  intense  as  to  promote  the  idea  of  suicide.  I 
have  observed  this  form  in  neurotic  subjects  sometimes  as 
the  result  of  influenza,  and  the  neuralgic  symptoms  may  be 
primary  or  periodic  in  the  course  of  the  disease.  But  I  have 
also  used  the  term  '  congestive,'  ior  neuralgic  does  not  include 
all  the  varieties  that  may  be  included  in  this  group.  The 
essential  point  is  that  there  is  a  direct  physical  cause,  and 
we  might  quite  properly  use  the  term  '  psycho-physical 
melancholia,'  so  as  to  embrace  many  kinds  of  causes.  It 
may  be  contended  that  many  causes  of  melancholia  would 
come  under  this  head  which  are  more  correctly  grouped 
otherwise,  e.g.,  aneemia  ;  but  what  I  wish  to  emphasize  is 
that  we  have  a  form  of  melancholia  which  has  a  distinct  and 
immediate  relation  to  physical  causes  —  that  neuralgia, 
cephalalgia,  congestive  brain  conditions,  may  make  life  so 
intolerable  from  physical  causes  alone  as  to  impel  to  suicide. 
In  everyday  experience  we  have  sea-sickness,  which  makes 
its  victims  indifferent  to  life,  and  patients  who  suffer  so 
much  that,  while  not  impelled  to  suicide,  they  would  willingly 
submit  to  narcotic  poisoning,  just  as  the  man  who  has  not 
courage  to  pull  his  own  loose  aching  tooth,  but  willingly 
submits  to  the  dentist. 

(3)  Acute  Melancholia  is  the  species  of  this  group  which 
gives  most  evidence  of  its  presence.  The  subjective  side 
has  now  an  obverse,  the  objective.  While  melancholia  is 
purely  subjective,  the  patient  is  negative  so  far  as  any 
audible  sign  is  concerned.  When  he  begins  to  make 
known  his  grief,  we  say  he  is  objective — he  puts  himself 
en  evidence.  You  have  now  to  look  behind  the  objective 
state  that  you  may  understand  wherefrom  it  springs.  Is  it 
the  mere  outpouring  in  the  channels  of  expression  by  cry 
and  speech,  by  tone  and  gesture,  by  facial  expression,  attitude 
and  muscular  unrest  of  the  pent-up  well  of  bitterness  and 
grief  which  cannot  be  stemmed  back,  cannot  be  restrained  ; 


ACUTE  MELANCHOLIA  105 

or  is  it  due  to  incessant  torture  arising  from  delusions  of  a 
grief-stirring  character  ?  If  the  latter,  then  is  the  intellect 
involved  as  well  as  the  feelings  and  emotions.  There  is  a 
form  known  as  delusional  melancholia,  but  that  is  quite 
distinct  from  the  acute  form,  which  also  has  a  basis  of 
delusions,  and  often  hallucinations,  especially  of  hearing  and 
of  an  accusing  or  threatening  character.  It  may  be  so  acute 
as  to  cloud  over  the  consciousness  of  all  but  immediate  self, 
there  is  no  interest  in  life  or  its  affairs,  the  patient  admits 
her  neglect  of  duties  and  responsibilities,  but  in  the  same 
breath  comes  the  wail  :  '  I  cannot  help  myself.  I  am  un- 
done, a  mockery  and  a  shame  to  myself  and  others.'  Under 
the  influence  of  this  dreadful  depression,  she  may  refuse  food, 
or  show  little  inclination  for  it,  even  when  there  is  no  morbid 
prompting  of  a  delusional  state.  She  may  say  that  she  has 
no  stomach,  that  her  food  is  not  paid  for,  that  it  contains 
poison,  that  she  must  die  of  starvation,  that  she  must  be 
sacrificed  to  save  her  children  ;  but  whatever  the  reason, 
refusal  of  food  is  a  frequent  symptom.  The  excitement  is 
evinced  usually  in  restless  walking  to  and  fro,  in  muscular 
agitation,  wringing  of  the  hands,  rhythmic  swaying  of  the 
body,  shaking  of  the  head,  attitudes  of  supplication  to  end 
her  life,  to  take  her  out  of  this  misery,  loud  lamentations, 
interrogatories,  '  Am  I  to  be  killed  ?'  '  Are  my  children  dead  ?' 
'  Is  my  husband  sacrificed  for  me  ?'  The  acute  melancholic  is 
sleepless,  unable  to  sit  quiet  for  a  moment,  to  fix  his  thoughts 
on  anything  beyond  his  own  miserable  feelings  and  ideas. 
The  melancholic  is  usually  timid,  afraid  of  many  things, 
concerned  and  anxious ;  and  except  in  acute  or  impulsive 
states,  suicidal  attempts  are  often  half-hearted.  The  attempt 
may  succeed,  however,  from  an  accession  of  impulsive  energy 
when  least  expected,  and  it  is  well  to  be  always  on  guard 
with  such  cases,  especially  silent  ones  who  are  given  to 
hiding  themselves.  The  patient  may  have  suggestions  and 
impulses  not  only  to  destroy  herself,  but  others  as  well,  e.g., 
herself  and  her  own  family.  There  are  diurnal  variations  in  the 
severity  of  the  symptoms,  which  are  more  acute  in  the  morn- 
ing and  forenoon  as  a  rule  ;  but  they  may  be  stimulated  into 
fresh  intensity  by  injudicious  remarks  or  mistaken  sympathy. 


io6  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

We  cannot  resist  the  impression  that  the  noisy  acute 
melanchoHc  is  often  more  really  selfish  and  engrossing  than 
silent  cases,  which  often  suffer  as  real  misery  quietly,  and 
never  speak  of  it.  The  silent  battles  with  it  in  her  own  soul ; 
the  noisy  so-called  acute  case  appeals  to  every  passer-by  for 
help  and  sympathy.  Given  two  men  or  women  seized  with 
the  same  delusion,  acting  on  each  with  equal  intensity,  the 
outlet  in  each  and  the  objective  phenomena  are  not  neces- 
sarily the  same.  The  acute  is  perhaps  only  acute  in  its 
expression,  and  not  always  as  regards  the  mental  pain 
itself. 

(4)  Delusional  Melancholia  has  been  so  named  from  the 
fact  that  the  under-current  of  melancholia  may  appear  sub- 
acute, while  delusions  are  prominent  and  the  distinctive 
feature  of  the  disease.  There  may  be  little  outward  expres- 
sion, and  no  uncontrollable  agitation,  and  the  patient  may 
be  able  to  emplo}^  herself.  The  delusions  are,  of  course,  of 
melancholic  t}'pe,  and  as  a  rule,  however  they  may  vary  in 
their  expression,  the  essential  character  is  almost  the  same, 
and  they  are  often  fixed  for  months  and  years.  This  form 
of  melancholia  has  exacerbations  of  uncontrollable  excite- 
ment sometimes,  when  it  partakes  for  a  time  of  the  acute 
form.  Clouston  observes  that  in  this  form  the  delusion 
stands  out  so  that  the  friends  of  the  patient  call  it  the  cause 
of  his  disease,  and  say  that  if  he  could  get  rid  of  it  he  would 
be  all  right.  It  is  with  such  cases  especially  that  one  is 
tempted  to  argue,  and  yet  how  hopeless  it  is  to  do  so,  for 
there  is  the  pathological  condition  behind  it  of  which  it  is 
the  unavoidable  imperative  expression. 

(5)  Hypochondriacal  Melancholia.  —  This  is  akin  to  the 
preceding,  but  the  delusions  have  reference  to  the  health  of 
the  individual.  Such  patients  often  become  a  prey  to  the 
most  torturing  ideas  regarding  their  viscera,  usually  the 
stomach  or  bowels.  The  mind  centres  morbidly  round  the 
one  idea,  and  to  some  the  act  of  defecation  is  the  primary 
function  of  their  existence.  I  have  known  a  most  self- 
respecting  fellow  so  carried  away  with  joy  because  his  bowels 
were  relieved  after  an  interval  of  three  days,  that  he  actually 
shouted  it  out  to  his  medical  attendant  in  the  presence  of 


RESISTIVE  MELANCHOLIA  T07 

many  strangers.  He  had  been  possessed  with  the  idea  that 
his  bowels  were  permanently  closed,  and  a  day  or  two  after 
the  dehision  took  hold  of  him  again.  Such  patients  often 
have  a  sinking  or  burning  feeling  at  the  epigastrium,  and  a 
fulness  or  lightness  in  the  head.  The  delusions  are  of  many 
kinds,  e.s^.,  that  the  patient  has  no  stomach,  that  his  heart 
has  disappeared,  that  his  brain  is  rotting,  or  his  inside  being 
burned  out. 

(6)  Resistive  Melancholia.  —  Clouston  gives  this  a  special 
place,  but  there  is  a  tendency  to  multiply  names  according 
to  symptoms,  so  that  the  varieties  of  melancholia  in  some 
text-books  are  legion.  That  a  resistive  character  is  well 
marked  in  some  cases  is  true,  but  the  associated  symptoms 
are  not  always  alike,  for  sometimes  there  is  excitement, 
sometimes  reticence,  and  even  stupor.  It  matters  not  what 
you  want  such  a  patient  to  do,  the  spirit  of  obstinacy  is 
strong.  He  will  not  voluntarily  do  anything  for  himself, 
will  not  initiate  and  carry  on  any  occupation,  however  easy 
and  trifling ;  but  he  will  expend  a  great  amount  of  energy  in 
resistance,  which  well  and  voluntarily  directed  would  have 
accomplished  some  good  work. 

(7)  The  silent  melancholic  who  never  speaks  is  not  so  sure 
of  being  noticed  as  her  noisy  sister.  Her  absolute  negation 
does  not  attract  notice  except  by  contrast.  Yet  she  should 
never  be  lightly  regarded,  for  there  is  often  here  a  hidden  fire 
of  resolution  and  insane  purpose,  and  such  are  often  the 
most  methodical  determined  suicides,  waiting  and  watching 
for  their  opportunity.  Suicide,  as  already  observed,  may 
arise  out  of  sudden  impulse,  a  sudden  accession  of  courage 
to  do  the  deed,  or  it  may  be  deliberately  planned  and  un- 
flinchingly executed.  The  silent  melancholic  may  think 
acutely  and  feel  intensely  behind  a  veil  of  quiet,  unobtrusive 
sorrow,  which  does  not  express  itself  so  significantly  as  to 
suggest  suicide.     Of  such  cases  always  beware. 

The  physical  symptoms  may  now  be  dealt  with  as  they 
refer  generally  to  all  the  foregoing,  and  do  not  necessarily 
apply  to  the  forms  afterwards  to  be  described.  As  a  rule, 
the  bodily  functions  work  at  a  slow  pace,  and  with  a  lack  of 
energy  which  affects  nutrition.     The  melancholic  is  almost 


io8  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

invariably  thin,  poorly  nourished,  and  the  vegetative  functions 
are  much  in  need  of  stimulation.  The  tongue  is  usually 
furred,  the  appetite  nil  or  impaired,  the  alimentary  canal 
dr}',  and  the  digestive  secretions  reduced  in  quantity  and 
vitality,  so  that  dyspepsia  and  foetor  of  breath  are  common. 
The  bowels  are  confined,  the  skin  dry,  and  the  urine  is  of 
low  specific  gravity,  and  not  increased,  but  rather  diminished 
in  quantity.  The  pulse  is  slow  and  small  in  volume,  unless 
there  is  suppressed  or  acute  excitement ;  the  body  heat  is 
diminished,  especially  at  the  extremities,  except  when  there 
is  muscular  agitation.  Without  going  further,  it  may  be 
added  in  a  word  that  sluggish  movement  and  restricted  out- 
put is  characteristic  of  all  the  functions. 

(8  and  g)  Chronic  Melancholia,  with  which  may  be  included 
Senile  Melancholia,  is  the  mechanical  expression  without  the 
psychic  equivalent.  The  expression  becomes  an  automatic 
discharge  ;  the  mental  pain  has  considerably  lessened  or  dis- 
appeared. What  would  be  thought  of  the  mental  distress  of 
a  chronic  melancholic  now  verging  on  senilit}^  who  cries, 
*  Will  you  let  me  home  ?  Will  you  let  me  home  ?  there's 
no  more  beds ;  you're  going  to  kill  me  !'  and  in  a  twinkling, 
without  warning,  trips  you  ignominiously  where  you  stand, 
and  the  next  moment  with  perfect  unconcern  says,  '  Will 
you  give  me  a  chew  of  tobacco  ?'  The  chronic  stage  is 
reached  onh'  after  several  years,  for  mental  deterioration 
does  not  occur  so  quickly  as  in  mania.  Many  cases  of  senile 
melancholia  are  too  demented  to  feel  sorrow  of  a  purely 
mental  character.  Their  so-called  melancholia  is  often  the 
reflex  expression  of  physical  breakdown  or  discomfort, 
childish  pettishness  of  old  age,  or  a  habit  of  grumbling  which 
has  grown  upon  them  with  advancing  years.  It  is  as  much 
a  melancholia  as  the  cry  of  a  hungry,  sick,  or  spoiled  child, 
and  no  more.  They  do  not  emaciate  except  as  a  result  of 
senile  atrophy,  and  the  chronic  melancholic,  when  leaving 
the  more  acute  period  behind  him,  gets  fat  and  robust 
physically. 

(lo)  Melancholia  with  Stupor. — This  has  been  regarded  by 
Baillarger  and  Regis  as  the  most  extreme  degree  of  melan- 
cholic   depression.     In  it  a   state  of  stupor   prevails  which 


MELANCHOLIA    WITH  STUPOR  109 

implies  a  suspension  of  movement,  and  it  may  be  of  volition, 
although  this  is  not  so  certain.  Indeed,  of  some  cases  it  is 
evident  that  they  are  resistive  melancholies  when  roused  out 
of  the  stupor  by  attempts  to  feed  them.  That  the  suspen- 
sion of  motor  activities  betokens  hyperacute  melancholia  is 
not  an  opinion  that  carries  conviction  on  the  face  of  it ;  but 
that  a  weak  brain  has  succumbed  without  a  struggle  to  a 
depressing  cause,  which  would  produce  the  mildest  melan- 
cholia in  another,  is  probably  nearer  the  truth.  In  melan- 
cholia with  stupor  delusions  are  present.  We  have  learned 
from  patients  who  recovered  that  they  are  sometimes  of  a 
terrifying  kind  and  paralyze  as  does  a  nightmare,  and  they 
may  be  regarded  as  somewhat  of  the  nature  of  obsessions, 
predominant  ideas,  which  the  mind  is  unable  to  get  rid  of, 
and  which  control  and  inhibit  all  outward  manifestations. 

Melancholic  stupor  is  more  frequent  among  females,  though 
men  are  not  by  any  means  exempt.  It  is  particularly  liable 
to  occur  during  adolescence,  among  hereditary  weaklings, 
and  this  of  itself  indicates  instability  of  brain,  and  an  easy 
prey  to  depressing  influences.  Many  adolescents  are  subject 
to  lapses  into  stupor  after  acute  excitement,  and  a  number 
lapse  right  away  into  prolonged  or  permanent  stupor  with 
only  a  brief  prelude  of  melancholia.  In  the  puerperal  state 
primary  or  secondary  stupor  is  often  found,  associated  with 
melancholic  consciousness.  It  is  found  also  as  a  sequel  of 
masturbation,  and  one  such  case  under  my  care  remained 
in  this  state  for  two  years.  The  symptoms  of  melancholic 
stupor  are  all  negatives.  The  most  extreme  case  I  ever 
knew  lay  like  a  log,  perfectly  limp,  pale,  and,  except  for  the 
brightness  of  his  eyes,  to  all  appearance  dead.  His  muscu- 
lature was  flaccid  and  unresisting,  his  joints  loose,  his 
movement  nil,  even  his  reflexes  gone,  and  his  sensibility 
impaired.  He  was  fed  artificially  and  passively,  offering  no 
resistance  for  two  years,  and  yet  was  conscious  all  the  time, 
as  we  afterwards  learnt,  and  was  able  to  relate  from  memory 
many  of  the  events  incidental  to  his  long  period  of  suspended 
animation.  When  he  had  made  a  partial  recovery  and  gone 
home,  I  called  on  him  for  the  purpose  of  eliciting,  if  possible, 
information  regarding  his  previous  mental  state.     He  insisted 


no  CLINICAL  MANUAL  OF  MENTAL- DISEASES 

on  being  alone  with  me,  and  was  very  mysterious  in  his 
manner,  and  I  had  difficulty  in  overcoming  his  reticence. 
At  last  I  learned  that  his  state  of  torpor  was  due  to  a  delu- 
sion which  may  be  described  as  one  of  double  identity.  He 
was  himself,  and  yet  overborne  by  another  higher  and  spiritual 
self  which  paralyzed  him  completely.  He  confessed  to  having 
been  much  addicted  to  masturbation  in  previous  years. 

Melancholia  with  stupor  is  therefore  a  condition  in  which 
movement  is  suspended;  but  consciousness  is  not  lost,  though 
it  is  characterized  by  depressing  thoughts  and  inhibitions. 
The  patient  is  more  helpless  than  an  infant,  for  the  latter  at 
least  will  suckle  if  it  gets  a  chance.  The  calls  of  nature  are 
not  responded  to  ;  the  patient  has  to  be  spoon-fed,  and  even 
then  there  is  risk  of  choking.  Often  the  stomach-tube  has 
to  be  used.  Digestion  is  feeble,  sensibility  and  the  reflexes 
generally  are  impaired,  the  musculature  is  weakened,  and 
there  is  drooping  of  the  head  and  shoulders.  The  circula- 
tion and  respiration  are  enfeebled,  and  the  extremities  are 
cold.  While  there  is  no  strained  attention  and  observation, 
much  is  being  observed  without  apparent  effort,  and  the 
memory  retains  a  good  deal.  Depressing  delusions  prevail, 
and  have  an  inhibitory  effect  on  nervous  energy. 

Such  a  patient  with  her  food  before  her  will  take  a  long 
time — if  she  tries  to  feed  herself — in  carrying  a  spoon  to  her 
mouth.  If  you  watch  her  at  a  distance,  without  appearing 
to  observe,  you  may  notice  the  feeble  movements  of  the 
hand  holding  the  spoon  ;  sometimes  it  is  lifted  and  falls 
away  again,  and  this  may  be  repeated  several  times.  There 
seems  to  be  a  faint  ebb  and  flow  of  nervous  energy,  an  effort 
of  will,  but  a  very  feeble  one  ;  and  in  the  end  the  nurse  lifts 
the  spoon  to  the  patient's  mouth,  and  the  food  is  slowly 
swallowed,  never  chewed  ;  that  would  mean  an  expenditure 
of  energy  which  is  not  in  store.  Another  patient  of  the 
same  class  will  resist  only  when  roused  up,  but  otherwise 
be  negative  and  motionless.  She  may  not  hold  a  spoon  in 
her  hand,  but  will  perhaps  open  her  mouth,  and,  if  she  does 
not  without  pressure,  may  at  least  swallow  if  the  food  is 
placed  inside  it.  There  are  various  gradations  in  the  depth 
of  stupor,  in  the  difficulty  of  rousing  the  patient,  and  the 


K  AT  AT  ON  I A  AND  CATALEPSY 


amount  of  response  which  can  be  obtained.  If  you  get  any 
movement  at  all,  it  is  the  sitting-down  movement,  for  the 
minimum  of  volition  is  required  to  execute  it.  It  requires 
more  volitional  energy  to  rise  than  to  sit,  to  raise  the  arm 
than  to  let  it  fall ;  the  movement  is  positive  in  the  one  case, 
while,  aided  by  the  law  of  gravity,  it  is  almost  negative  in 
the  other. 

In  these  cases  there  is  undoubted  anaemia,  and  frequently 
the  catamenia  are  absent.  With  their  bodily  functions  so 
imperfectly  performed,  and  the  amount  of  oxygen  entering 
the  blood  so  much  below  par,  it  is  not  surprising  that  they 
are  often  very  unsatisfactory  cases,  and  that  tubercular  and 
other  affections  of  low  inflammatory  type  find  them  an  easy 

prey. 

In  relation  to  melancholic  stupor  may  here  be  described 
katatonia  and  catalepsy. 

The  term  '  katatonia'  was  introduced  by  Kahlbaum.  It  is 
doubtful  if  it  can  be  separately  distinguished  from  melan- 
cholic stupor  on  the  one  hand,  or  anergic  stupor  on  the 
other.  Typical  cases  have  been  described  which  pursued  a 
definite  course  in  stages  as  follows  :  melancholic  depression, 
then  maniacal  or  melancholic  excitement,  then  the  condition 
which  gives  a  name  to  this  variety  of  mental  disease,  rigid 
immobility,  and  lastly  recovery  or  dementia.  Now,  it  is  to 
be  observed  that  in  not  a  few  cases  of  melancholic  stupor 
there  is  distinct  passive  resistance,  an  iron  hardness  of 
muscle,  as,  for  example,  in  trying  to  raise  the  drooping  head 
and  neck,  or  to  raise  the  arm  which  hangs  idly  by  the  side. 
But  it  has  been  sometimes  observed  that  monotonous  auto- 
matic movements  occur  from  time  to  time — what  are  known 
as  stereotyped  movements.  Other  symptoms,  such  as  mutism, 
refusal  of  food,  or  its  opposite,  excessive  eating,  excitement 
of  theatrical,  declamatory  character,  verbigeration,  cyanosis, 
and  salivation,  have  been  described.  While  the  researches 
of  Kahlbaum  merit  respectful  attention,  and  it  may  yet  be 
possible  to  differentiate  katatonia  and  enucleate  it  from  other 
forms  of  mental  disorder,  we  are  at  present  unable  to  do 
more  than  refer  to  it  as  in  many  respects  symptomatically 
near  akin  to  melancholic  stupor. 


112  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

Catalepsy. — The  patient  cannot  move  his  hmbs  ;  but  their 
position  can  be  altered  by  another  person,  and  so  remain. 
Ask  the  patient  to  hold  out  his  arm  ;  there  is  no  response/ 
Draw  it  forward  yourself,  and  there  it  remains  till  you  place, 
it  back  again.  The  movements  may  be  called  dummy  move- 
ments. This  condition  is  often  intermittent,  and  is  found 
in  many  cases  of  stupor  from  time  to  time,  including  melan- 
cholic, anergic,  epileptic,  and  the  stupor  of  masturbation. 

i^TIOLOGY. 

There  is  no  specific  cause  which  can  be  said  to  produce 
melancholia  and  nothing  else.  In  the  general  remarks 
on  causes,  all  that  need  be  said  has  been  already  told ; 
yet  we  may  sum  up  now  in  one  sentence  :  depressing  con- 
ditions, moral,  mental,  physical,  may  have  a  depressing 
effect  on  the  emotions ;  but  some  people  are  hereditarily 
prone  to  fly  like  a  shuttlecock  from  grave  to  gay  and  back 
again,  so  that  it  is  difficult  to  say  'how  depressing  causes  will 
affect  them. 

Differential  Diagnosis. 

Regarding  this  there  is  little  to  be  said.  The  essential 
feature  in  melancholia  is  mental  distress,  a  distinct  mental 
anguish  with  or  without  any  qualifying  conditions  of  excite- 
ment, delusions,  hypochondria.  The  depression  may  not  be 
acute  ;  it  may  be  so  slight  as  to  raise  the  question  of  whether 
you  have  to  do  with  melancholia,  or  what  has  hitherto  been 
called  the  mania  of  suspicion,  unseen  agency  or  persecution, 
which  is  not  mania,  neither  is  it  a  melancholia,  because  the 
state  of  mental  feeling  is  consistent  with  a  fairly  contented 
mental  existence. 

Prognosis. 

The  prognosis  of  simple  melancholia  is  good,  and  also 
of  acute  melancholia ;  that  of  the  other  forms  is  only  less 
favourable,  but  it  may  be  regarded  as,  next  to  mania, 
the  most  hopeful  of  all  forms  of  insanity.  The  average 
duration  of  the  disease  before  recovery  is  manifested  is 
greater  than  in  mania.  A  returning  sense  of  humour,  evi- 
dence that  the  patient's  mind  is  being  actively  {not  passively) 


TREATMENT  OF  MELANCHOLIA  113 

interested  in  matters  outside  herself,  a  disposition  to  work, 
interest  in  personal  appearance,  gain  of  weight,  return  of 
catamenia,  are  all  good  signs. 

Treatment. 

The  treatment  of  melancholia  is  to  be  regulated  in  accord- 
ance with  two  principles :  first,  that  there  may  be  causes  or 
physical  conditions  to  remove  ;  second,  that  the  patient  must 
be  drawn,  and  if  need  be  forced,  out  of  himself.  If  you  regard 
melancholia  as  introspective  selfishness,  you  will  see  the  neces- 
sity for  driving  the  man  out  of  himself,  and  just  as  bodily  pain 
requires  a  counter-irritant,  the  mental  pain  must  be  relieved 
by  external  application,  even  if  you  have  to  make  the  melan- 
cholic angry,  which  it  is  possible  to  do,  and  an  angry  melan- 
cholic is  the  most  promising  of  all.  Such  cases  do  best 
with  asylum  treatment.  I  have  in  view  at  the  present 
moment  three  cases  of  melancholia,  all  treated  for  months 
in  private  lodgings,  having  their  own  attendants,  and  as 
much  individualizing  treatment  as  it  was  possible  to  give 
them.  Individualizing  treatment  is  apt  to  foster  the  morbid 
introspection  and  magnify  the  ego.  They  were  well  fed, 
medically  studied — too  much  so,  perhaps — built  up  physically ; 
but  they  did  not  improve,  for  their  selfish  introspection  was 
not  uprooted,  but  rather  fostered.  They  were  all  sent  to 
asylums,  and  in  a  few  months  recovered.  Why  ?  Because 
there  is  less  room  for  emotional  self-indulgence  in  asylums. 
The  melancholic  is  less  noticed,  less  made  of,  subjected  to 
discipline,  made  to  do  things  whether  he  will  or  not,  roused 
out  of  himself,  stirred  up  to  take  notice  of  objects  and  aims 
outside  himself,  and  made  to  work.  The  treatment,  then, 
is  to  be  regulated  (i)  by  individual  necessity  of  constitution 
and  bodily  health,  by  attention  to  hygienic  laws  ;  (2)  by 
insisting  on  mental  occupation  outside  himself,  and  par- 
ticularly by  giving  him  physical  work  that  will  force  him  to 
concentrate  thought  away  from  self;  (3)  by  attention  to  his 
sleeping  habits,  and  by  guarding  against  suicide.  Melan- 
cholic depression  is  usually  most  acute  in  the  early  morning, 
and  suicidal  impulses  are  then  most  common.     The  melan- 


114  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

cholic  is  usually  worst  in  the  morning,  and  best  in  the  even-^ 
ing.     It  is  not  infrequently  the  opposite  in  acute  mania,    j 

In  many  cases  there  is  refusal  of  food,  and  great  pains  and 
patience  must  be  exercised  with  such  cases,  and  a  search 
must  be  made  for  the  cause,  whether  mental  or  physical,  and 
any  indications  for  treatment  that  may  be  thus  discovered 
must  be  followed.  Tonics  are  often  beneficial.  Sleep  must 
be  restored  if  it  is  wanting,  and  it  is  well  not  to  resort  to 
drugs  if  they  can  possibly  be  done  without,  and  if  a  drug  is 
necessary  use  bromide,  as  the  least  harmful  first,  especially 
in  neuralgic  cases. 

Attention  to  the  bowels  is  also  of  very  great  importance. 
Whether  it  be  a  symptom  or  a  cause,  constipation  helps  to 
produce  a  vicious  circle  of  hepato-intestinal  disorder,  .and 
must  be  fought  against.  You  will  note  that  some  melan- 
cholies are  of  distinctly  bilious  temperament,  and  in  such 
cases  a  hepatic  stimulant  is  often  an  indication  of  great 
importance.  The  mental  relief,  the  melting  away  of  the" 
cloud  of  depression,  after  a  free  discharge  of  bile. is  an  experi- 
ence in  sane  life  which  speaks  eloquently  regarding  the  rela- 
tions of  the  liver  and  the  mind. 

It  may  be  well  to  prescribe  a  diet  scale  for  your  patient, 
suited  to  his  particular  needs,  and  you  will  be  well  advised 
in  excluding  from  it  anything  which  may  favour  the  intro- 
duction of  oxalates  into  the  system,  for  many  patients  of 
melancholic  temperament  are  susceptible  to  their  influence, 
which  increases  the  depression.  It  is  assumed  that  the 
heart  and  lungs  have  been  examined,  and  it  is  of  importance, 
for  diseases  of  these  organs  may  have  a  distinct  causal  rela- 
tion to  the  melancholic  state,  and  their  treatment  n>ay  bene- 
ficially affect  it.  , 

In  the  treatment  of  the  melancholia  with  stupor,  the  chief 
point  is  to  individualize  with  unwearying  diligence,  rouse 
him,  make  him  walk,  rub  him  that  his  circulation  may  be 
kept  up.  Keep  him  always  warm,  and  give  him  his  food 
finely  triturated,  and  as  far  as  possible,  .predigested. 
Galvanism  or  the  interrupted  current  may  do  good.  Th^y 
will  have  more  or  less  a  rousijig  effect,  and  if  it  is  very- 
temporary  and  disheartening,  try  again,  for  sl^jpof  cases  are 


CLINICAL  ILLUSTRATIONS  115 

often  very  hopeful  cases  if  treated  hopefully  and  heartily. 
Blistering  the  head  is  sometimes  of  service,  for  it  appears  to 
rouse  the  patient,  and  promotes  a  stimulation  of  the  nervous 
system.  It  should  be  gentle  and  frequently  repeated.  If 
too  heroic  and  exciting  more  harm  than  good  may  be  done. 
It  will  utterly  fail  in  some  cases,  and  is  indicated  rather  in 
the  stout  lethargic  cases. 

Clinical  Illustrations. 

Simple  Melancholia,  almost  negative  in  character,  with 
exaggerated  feelings,  e.g.,  of  being  walled  in. 

Mrs.  Isabella  D.,  get,  47. — History  :  husband  and  self  were 
caretakers  of  hospital  abroad.  Situation  lost  owing  to  hus- 
band's drinking  habits — poverty  and  hard  times  followed,  and, 
though  due  to  this,  not  till  seven  months  after  did  depression 
come  on,  and  then  quite  suddenly.  She  had  a  peculiar  sensa- 
tion in  the  head  (not  pain),  and  jumping  out  of  bed  cried, 
'  What's  that  ?'  and  thereafter  was  quite  uninterested  in  what 
was  going  on  around  her.  Since  then  (October,  1893)  she 
remarked,  '  I  had  no  feeling.'  This,  by  the  way,  is  a  common 
expression  vs^ith  melancholies  ;  but  it  merely  means  that  she 
had  no  interests,  that  nothing  happening  around  could  make 
any  impression  on  her — her  senses  of  pain,  touch,  etc.,  were 
quite  acute.  She  had  the  feeling  of  being  hemmed  in  as  if 
by  walls,  and  so  also  on  board  ship  when  coming  home. 
She  was  perfectly  conscious  that  there  were  no  real  walls, 
and  that  the  feeling  was  there  without  any  real  external 
cause.  When  convalescent,  she  said,  '  I  have  been  quite 
conscious  of  what  was  going  on  during  all  this  time,  and 
have  still  a  most  distinct  recollection  of  many  things  in 
which,  however,  I  had  absolutely  no  interest  at  the  time.' 
This  patient  made  an  excellent  recovery  after  being  melan- 
cholic for  two  years. 

Neuralgic  or  Congestive  Melancholia  (psycho-physical). — 
Four  illustrations  are  given  : 

I.  Jane  C. — Neuralgia  of  face,  very  much  run  down  ;  cut 
throat,  and  jumped  out  of  window  ;  restless,  despondent, 
wants  to  be  coddled.  Under  bromide,  good  diet,  and 
stimulants  she  recovered. 

8—2 


ii6  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

2.  James  O. — Influenza;  severe  facial  neuralgia  followed; 
very  thin  and  cadaverous,  miserable  and  discontented.  Under 
bromide,  good  diet,  and  stimulants  he  recovered. 

3.  John  B.-^-Large,  stout,  full-blooded  man ;  felt  a  sense 
of  fulness  and  oppression  so  unbearable  that  he  cut  his 
throat  to  relieve  it.  Instinctively  Nature  seemed  to  suggest 
this  remedy,  so  he  said  afterwards  when  he  recovered  ;  and, 
beyond  getting  relief  in  this  way,  he  said  he  had  no  intention 
of  committing  suicide.  In  this  case  it  was  found  that  the 
bowels  were  much  constipated,  and  a  sharp  purge,  which 
had  to  be  repeated,  produced  distinct  and  immediate  relief 
mentally  and  physically. 

4.  John  B.  junr.  —  A  }-oung,  hard-working,  ambitious 
engineer,  who  studied  night  after  night  till  the  small  hours  ; 
a  most  impulsive  suicide.  He  had  to  be  held  by  an  attendant 
all  the  time  when  not  in  the  padded  room  ;  heard  voices  im- 
pelling him  to  suicide  by  whatever  means  possible ;  he  cut 
his  throat  with  broken  glass,  and  dashed  through  windows 
with  sudden  impetuosity.  Was  known  to  be  ^■ery  costive  ; 
enemata  daily,  with  little  effect.  Ischial  abscess  appeared, 
and  in  order  to  treat  it  successfully  it  was  resolved  to 
thoroughly  clear  out  the  bowels,  and  then  rest  them  for  several 
days.  The  mental  condition  still  the  same.  After  several 
strong  purgatives  were  given,  assisted  by  enemata,  the 
bowels  discharged  very  large  quantities  of  most  foul-smelling 
faeces.  Head  much  relieved ;  hallucinations  disappeared, 
and  also  suicidal  impulse.  Recovered  mentally  before  ischial 
abscess  had  quite  healed.  On  recovery  he  said  that  the 
tension  in  his  head  was  so  unbearable,  apart  altogether  from 
the  hallucinations,  that  life  was  not  worth  living. 

Acute  Melancholia  (from  a  clinical  lecture). 

Mrs,  J.  T.,  set.  56. — Second  attack  ;  is  a  very  striking 
example.  She  is  hollow-e3'ed,  with  dark  rings  around,  and 
all  the  appearance  of  intense  wakefulness,  almost  amount- 
ing to  delirium  ;  but,  like  most  cases  of  acute  melancholia, 
her  excited  speech  is  fairly  coherent.  Remember  that  she 
is  not  always  so  acutely  excited  as  at  the  present  moment  ; 
she  has  quiet  and  noisy  intervals,  but  as  a  rule  she  is  as  you 
see  her  now.     She  wrings  her  hands,  wails  loudly,  and  anon 


CLINICAL  ILLUSTRATIONS  117 

shrieks.  She  tears  her  hair,  and  the  mental  thread  of  her 
excitement  is  revealed  in  the  expressions  constantly  re- 
peated :  '  I  have  lost  my  Saviour — I  have  lost  my  Saviour  ! 
Condemned  to  the  bottomless  pit  —  the  bottomless  pit!' 
Observe  the  furious  state  of  unrest,  an  aggressive,  fighting, 
struggling,  and  anon  despairing  expression.  She  requires 
forced  feeding.  She  is  most  impulsive,  and  requires  to  be 
carefully  watched ;  the  attention  of  the  nurses  must  never 
be  allowed  to  stray  from  watching.  She  makes  sudden  and 
violent  rushes,  and  tried  to  put  her  head  in  the  fire ;  butted 
her  head  against  the  door  ;  wanted  to  get  to  the  river  Clyde  ; 
tried  when  at  home  to  get  hold  of  a  razor  ;  quivers  with 
excitement  at  times,  and  every  now  and  again  there  is  a 
fresh  climax.  Hallucinations  of  sight  and  hearing.  This 
patient  was  treated  with  Potas.  Brom.  and  Tinct.  Cannabis 
Indica,  and  recovered. 

Delusional  Melancholia  (clinical  lecture). 

Three  cases  only  will  be  shown  you,  for  this  special  form 
of  melancholia  may  be  regarded  as  the  connecting-link 
between  melancholia  proper  and  partial  insanity,  to  be 
treated  of  in  the  next  chapter.  It  is  difficult  to  locate 
definitely  some  cases  in  either  group,  for  in  melancholia  the 
integrity  of  the  reasoning  faculty,  apart  from  delusions,  is 
often  very  slightly  affected.  Many  melancholies  are  exceed- 
ingly useful  members  of  society. 

B.  G.  H.,  set.  67. — This  lady  is  the  miserable  prey  of  one 
fundamental  delusion — that  the  devil  has  taken  possession  of 
her  and  controls  her,  and  that  he  impels  her  to  drown  her- 
self. The  devil's  suggestions  are  thoughts  which  tick  so 
loudly  in  her  brain  that  she  can  almost  believe  them  to  be 
the  utterance  of  a  voice  within  her  head.  She  is  rather 
restless,  nervous,  and  suffers  from  palpitation.  Her  bodily 
condition  is  much  impaired,  but  it  will  probably  improve,  as 
there  are  indications  for  hopeful  treatment,  and  she  will 
likely  recover. 

J.  B.  M.,  get.  50. — This  patient  is  depressed,  and  at  the 
same  time  bewildered.  She  cannot  understand  exactly 
where  she  is  ;  but  she  has  the  feeling  that  everything  is 
changed — trees,    animals,    everything   in    her  environment  ; 


ii8  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

that  she  is  a  wheel  continually  going  round.  She  mopes 
about  doing  nothing  but  bemoaning  this  strange  condition 
whereby  she  is  no  longer  her  former  self. 

Richard  Mac. — This  young  man  is  twenty-four ;  has  been 
insane  a  year,  and  the  cause  is  said  to  be  probably  masturba- 
tion. We  have  no  reason  to  think  so  since  he  came  here 
nine  months  ago.  He  is  not  deeply  depressed.  He  tells  us 
a  very  sad  story  which  he  believes  to  be  true  ;  but  his  face 
rather  belies  the  truth  of  it,  for  though  he  is  not  bright  and 
cheerful,  melancholy  is  not  clearly  imprinted  there. 

Good-morning,  Dick. 

A.  Look  here,  Clark,  what  are  you  going  to  do  with  those 
murderers  ?  They've  been  discharging  electricity  through 
my  lungs. 

Q.  Who  are  the  murderers  ? 

A.  There's  Blair  :  you  must  have  him  tried  for  it. 

Q.  But  I  thought  you  told  me  yesterday  that  Colville  was 
the  man  ? 

A.  Yes,  Colville  and  Blair,  and  the  Americans  ;  they've 
committed  seventy  murders  between  them. 

This  is  a  case  of  delusional  melancholia  nearly  allied  to 
what  used  to  be  called  the  monomania  of  persecution  and 
unseen  agency.  The  delusions  ne^•er  vary,  they  are  perfectly 
consistent  from  month  to  month  ;  but  except  that  this  man 
is  rarely  seen  to  smile,  that  life  is  for  him  a  very  serious 
matter,  the  melancholia  is  only  slightly  in  evidence,  and  it 
does  not  prevent  him  engaging  in  useful  employment  every 
day,  nor  distract  his  mind  or  paralyze  his  energies.  By  some 
this  case  would  be  regarded  as  monomania  of  persecution 
rather  than  delusional  melancholia,  and  I  have  introduced  it 
here  with  a  point  of  interrogation  after  the  term  '  delusional 
melancholia.' 

Hypochondriacal  Melancholia  (clinical  lecture). 

Mary  Mac,  aet.  64. — This  is  a  case  of  mild  depression  so 
far  as  we  can  judge  outwardly,  and  the  delusional  character 
is  consistently  the  same.  She  believes  she  is  the  subject  of 
a  loathsome  disease,  and  has  infected  many  people  with  it. 
She  does  not  attribute  this  disease  to  any  malign  influence, 
to    persecution,    or    other    causes.      She    reproaches    herself 


CLINICAL  ILLUSTRATIONS  119 


alone.  She  has  for  years  complained  of  pain  in  the  right 
side,  and  from  this  has  arisen  the  idea,  from  a  morbid  sugges- 
tion of  her  own  rottenness,  that  she  is  the  subject  of  a  loath- 
some disease.  She  is  improving  in  physique,  gaining  weight, 
sleeping  better,  and  this,  taken  together  with  the  fact  that 
there  is  a  hereditary  history  in  her  case,  incHnes  us  to  believe 
that  she  will  recover.  After-history  :  she  fattened,  lost  her 
delusion,  and  with  it  the  melancholy,  and  was  discharged 
recovered. 

Matthew  A.,  a;t.  59. — This  man's  expression  is  now  stereo- 
typed after  years  of  melancholy.  He  has  distressing  sensa- 
tions of  a  burning  character  in  the  epigastrium,  and  he 
believes  that  he  has  no  stomach,. that  it  has  been  burned 
out  of  him,  that  his  bowels  have  been  destroyed,  and  that 
defecation  is .  impossible.  Thus  he  explains  the  constipa- 
tion for  which  we  are  treating  him. 

James  McA.,  set.  57. — Here  comes  a  man  who  is  always 
complaining,  always  grumbling.  He  says  he  doesn't  want 
food,  but  when  it  is  put  before  him  he  sometimes  eats  to 
gluttonous  excess.  He  doesn't  want  to  work,  and  if  he  is 
kept  in  the  house  he  is  miserable  and  groans  aloud.  He  is 
always  wanting  medical  examination — 'to  be  sounded.' 

Q.  How  are  you  ? 

A.  I'm  no  very  weel.     There's  plenty  of  doctors  here. 

Q.  Well,  what's  the  matter  ?     Tell  these  young  doctors. 

A.  Well,  you  see,  I  want  medicine;  I  canna  eat.  My 
inside's  closed  up.  My  bowels  is  costive  ;  my  throat's 
choked. 

This  man,  despite  these  delusions,  and  as  if  to  prove  that 
they  are  delusions,  eats  well  and  heartily,  but  sometimes 
overdoes  it,  and  then,  of  course,  has  reason  to  complain. 

Chronic  Melancholia. — Two  cases  will  be  here  contrasted. 

A.  W.,  get.  47. — This  man  has  been  shrouded  more  or  less 
deeply  in  melancholy  for  many  years.  The  melancholy  is 
genuine.  You  have  only  to  look  at  him  to  see  this,  for  his 
attitude  and  expression  are  silent  but  emphatic  witnesses  of 
his  state. 

Q.  Well,  sir,  how  are  you  ? 

A.  Just  the  same. 


I20  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

Q.  Were  you  ever  of  a  happy  disposition  ? 

A.  Not  very,  as  far  back  as  I  remember. 

Q.  As  a  boy,  did  you  ever  play  v^ith  other  boys  ? 

A.  Oh  yes. 

Q.  Can  you  tell  me  when  you  became  distinctly  melan- 
choly ? 

A.  About  the  age  of  eighteen. 

Q.  Have  you  ever  been  so  miserable  as  to  feel  that  life 
wasn't  worth  living  ? 

A.  No. 

Q.  Was  your  health  good  ? 

A.  Yes. 

Q.  Did  you  always  take  your  food  ? 

A.  Yes. 

It  is  very  probable  that  the  patient's  statement  as  regards 
his  health  may  require  a  qualification. 

Q.  Were  you  inclined  to  be  costive  ? 

A.  Yes,  all  my  days. 

Q.  Did  you  ever  have  bilious  attacks  ? 

A.  Yes,  often. 

Q.   Did  you  ever  throw  up  bile  ? 

A.  Yes  ;  after  taking  whisky. 

Q.  Did  you  drink  whisky  often  ? 

A.  No,  only  at  fair  time  and  New  Year. 

If  you  look  again  at  this  man,  you  will  observe  the  sallow, 
bilious  appearance  which  is  frequently  the  complexion  of 
melancholia.  This  man  has  very  little  initiative  ;  he  sits 
silent,  passive,  listless,  all  day,  and  whatever  he  does  is  done 
without  any  heart  or  soul  in  it.  His  case  is  one  of  simple 
melancholia  become  chronic  and  confirmed  after  many  years. 

Thomas  Mac,  set.  67. — The  next  case  wears  an  expression 
of  deep  melancholia  ;  he  is  less  silent  than  the  preceding, 
and,  as  he  proceeds  to  speak  with  us,  you  will  note  his 
childish  character,  and  the  evident  skin-deep  character  of 
his  melancholic  wailing  and  lamentation. 

Q.  Well,  Mac  ? 

A.  Is  my  son  here  ?  I  dinna  see  my  son.  They  told  me 
he  was  coming  to  see  me.  I  dinna  see  him.  Where  is  he  ? 
They  said  he  was  coming  to  see  me.     I  dinna  see  my  son. 


Plate  I.— MELANCHOLIA. 


SILENT    MELANCHOLIA, 


M.   C.       MELANCHOLIC    STUPOR. 


T.    M.    CHRONIC    MFXANCHOLIA. 


T.    Ci      CHRONIC    MELANCHOLIA. 
To  face  p.  1 20. 


R.    M. 
DELUSIONAL   MELANCHOLIA. 


CLINICAL  ILLUSTRATIONS 


Takes  a  seat. 

Q.  Who  told  you  to  sit  there  ? 

A.   I  don't  know ;  they  said  my  son  was  coming  to  see  me. 

Q.  How  are  you  to-day  ? 

A.   No  very  weel. 

Q.  What  is  the  matter  ? 

A.   I'm  very  bad.     I  haven't  had  a  bed  these  three  nights. 

Q.  You  can't  take  your  food  ? 

A.  No  (with  a  groan). 

Q.  You  are  very  miserable  ? 

A.  Yes  (with  a  groan). 

Q.  What  is  the  cause  of  your  misery  ? 

A.  I  want  hame.     The  folk  here  won't  let  me  hame. 

Q.  You  don't  get  any  pleasure  in  life  at  all  ? 

A.  No. 

Q.  You  don't  enjoy  a  smoke? 

A.  No  for  a  long  time. 

Q.  Do  you  remember  asking  me  for  tobacco  yesterday  ? 

A.  (with  feigned  surprise).  Was't  you  ? 

This  man  has  indulged  the  melancholy  wail  so  long  that 
he  couldn't  give  it  up  if  he  tried.  He  was  truly  very 
melancholy  once.  This  is  the  memory  of  it  stereotyped  in 
expression  only,  for  he  has  no  real  emotional  depression, 
and  enjoys  life  and  all  the  good  things  that  come  his  way 
as  well  as  anyone  I  know. 

Melancholic  Stupor  (clinical  lecture). — Three  cases  (all 
females,  all  Marys)  are  now  introduced. 

Mary  A.  is  tall,  extremely  thin,  drooping  gait,  and  head 
drops  on  chest. 

Mary  B.  is  tall,  thin,  extremely  pale  and  anaemic,  rather 
limp  and  gawky. 

Mary  C.  is  of  medium  height,  stout,  sallow,  of  heavy 
expression  and  lethargic. 

These  three  are  cases  of  melancholic  stupor,  and  this  is 
certain  from  the  fact  that  each  has  a  history  of  mental 
depression  and  causes  calculated  to  produce  anxiety  and 
depression.  But  what  evidence  is  there,  judging  merely  by 
their  present  condition,  that  they  are  cases  of  melancholic 
stupor  ?      Hitherto  the  principal  distinction  drawn  between 


122  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

melancholic  stupor  and  anergic  stupor,  of  which  we  shall 
speak  later  on,  was  that  of  apparent  consciousness  in  the 
former,  and  the  mind  an  absolute  negation  in  the  latter. 
Now,  in  each  of  these  three  cases  there  is  apparent  conscious- 
ness, and  this,  we  assume,  in  two  cases  merely  from  the 
facial  expression,  especiall}-  that  of  the  eye.  There  is  no 
reaction  to  stimulus  in  M.  C.  ;  but  Mary  x\.  resists  attempts 
to  feed  her,  though  she  never  speaks  or  reacts  in  any  other 
way.  She  is  particularly  resistive  when  medicine  is  put  into 
her  food,  which  shows  that  there  is  an  idea  behind  this 
resistiveness,  though  she  never  speaks.  This  patient  some 
weeks  ago  was  less  expressive,  her  eyes  were  usually  closed, 
and  if  opened  had  the  expression  of  gazing  sadly  into  space ; 
but  from  iirst  to  last  her  facial  expression  was  that  of  melan- 
cholia, statuesque,  immobile,  but  the  melancholic  expression 
was  graven  there. 

These  three  cases  of  melancholic  stupor  are  not  identical. 

Mary  A.  is  most  conscious  of  the  three.  She  observes  and 
turns  her  head,  and  follows  with  the  e3'es  during  the  last 
few  days,  and  she  resists. 

Mary  B.  comes  next  in  apparent  consciousness.  She  ob- 
serves, but  from  her  cephalic  formation  and  facial  expression 
she  is  evidently  not  of  so  high  a  type  of  intelligence  as  Mary  A. 
She  rises  from  her  chair  when  spoken  to,  and  when  told  will 
go  and  pull  Mary  C.  off  her  chair,  and  then  both  come  to  a 
standstill. 

]\Iary  C.  is  apparently  the  least  conscious  of  the  three.  Her 
facial  and  cephalic  configuration  are  better  than  Mary  B.'s, 
but  she  is  most  stuporose.  Of  will  there  is  none  ;  whether 
it  is  suspended  under  the  power  of  delusion  we  cannot  con- 
jecture. 

The  more  profound  the  stupor,  the  less  the  resistiveness 
(will  suspended),  the  less  the  sensibility  to  pain  or  touch  or 
special  sensations,  and  the  more  diminished  the  reflexes. 
It  vAll  be  noticed  that  these  three  patients  are  young  girls 
from  twenty  to  thirty  years  of  age.  I  wish  to  point  out  that 
youth  is  the  time  when  most  cases  of  stupor  arise,  and  the 
reason  is  a  weak  brain,  the  result  of  inheritance  and  feeble 
staying   power.     I    have    found    a    tendency  to    phthisis   in 


CLINICAL  ILLUSTRATIONS     ,  123 

several  cases,  and  you  will  observe  the  strumous  cicatrices 
in  Mary  A.  She  has  a  very  erratic  temperature  chart,  and 
we  are  suspicious  of  mischief  at  the  apex  of  the  right  lung. 
After-note  :  she  died  of  phthisis  seven  months  later. 

I  wish  now  to  direct  attention  to  one  case,  a  male,  who 
has  been  a  masturbator  all  his  life.  He  is  now  convalescent 
from  an  attack  of  melancholic  stupor,  during  which  he  was 
fed  by  stomach-pump,  and  states  that  he  was  under  the 
influence  of  delusions,  and  perfectly  conscious  all  the  time. 

Expression. — His  expression  did  not  express  obscuration 
of  the  mental  faculties  ;  the  features  were  relaxed.  The  face 
very  pale,  and  exhibiting  a  passive  though  serious  expres- 
sion. 

Attention. — The  faculty  of  attention  was  not  lost,  for  he 
followed  with  his  eye  the  various  movements  of  the  ophthal- 
moscopic mirror,  as  the  light  was  reflected  from  spot  to  spot 
towards  the  pupil.  While  lying  undisturbed  on  the  sofa,  he 
occasionally  turned  his  eye  in  the  direction  of  any  moving 
object.  How  far  this  was  purely  reflex  and  how  far  con- 
sciousness was  associated  with  it  we  were  of  course  unable 
to  determine. 

Sleep. — At  irregular  periods  he  appeared  to  fall  asleep. 
The  eyes  then  closed,  and  this  was  the  only  objective 
difference  between  his  sleeping  and  waking  state. 

Special  Senses. — {a)  Hearing  :  When  a  noise  was  made 
behind  him  he  was  seen  to  wink,  (b)  Seeing  did  not  appear 
to  be  impaired,  as  he  frequently  followed  movements  with 
his  eyes,     (c)  Other  special  senses  had  not  been  tested. 

Ordinary  Sensation. — (a)  Pain  :  No  response  elicited  by 
pricking  sharply  with  a  needle.  The  sudden  and  unobserved 
application  of  a  strong  interrupted  current  caused  him  to 
quickly  draw  away  the  part  stimulated,  {h)  Heat  and  cold  : 
Test-tubes  applied  to  the  skin,  alternately  hot  and  cold, 
gave  no  indication,  as  he  gave  no  response  verbally  or  other- 
wise, (c)  Touch  and  {d)  tickling  gave  likewise  negative 
results. 

Motor  Functions — {A)  Reflex. — (a)  Swallowing  normal; 
swallowed  saliva  readily  enough.  (6)  Coughing  when  back 
of  throat    tickled    sometimes.      This    reflex    irritability    has 


124  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

become  much  more  marked  during  the  last  few  weeks. 
(c)  Breathing  natural  and  quiet,  (d)  Micturition  normal. 
Penis  always  was  placed  in  an  indiarubber  urinal,  and  it  was 
found  that  micturition  took  place  after  decided  intervals, 
and  that  there  was  no  incontinence,  (e)  Defsecation  :  Was 
placed  on  the  seat  of  w.c.  at  stated  times.  There  was  no 
incontinence.  (/)  Eyelids  normal,  (g)  Skin  reflex  :  Absent 
in  axilla,  and  almost  entirely  in  soles  of  feet,  where  all  the 
toes  responded,  but  not  synchronously,  and  very  slightly. 
(h)  Tendon  reflex  :  Exaggerated  in  both  knees,  the  legs 
jerking  with  a  flail-like  movement. 

(B)  Voluntary  Movements. — Of  these  we  saw  practically 
nothing.  The  balance  between  the  extensors  and  flexors 
of  the  feet  was  lost,  the  legs  being  flexed,  and  the  shape  of 
the  feet  suggestive  of  extensor  paresis.  This  did  not  obtain 
in  the  case  of  the  hands. 

Vaso-Motor  and  Nutritive. — (a)  Local  congestions :  These 
were  readily  excited  by  external  irritation,  and  persisted  for 
a  long  time  after,  (b)  Pallor  extreme  all  over  the  body. 
(c)   No  oedema,     (d)  No  inflammation  or  wasting. 

For  a  few  weeks  the  interrupted  current  was  frequently 
applied  to  his  muscles  and  some  of  his  nerves.  The  nerve 
trunks  of  the  arm  and  face  were  those  chiefly  stimulated. 
This  appeared  to  rouse  him  somewhat,  especially  when  the 
facial  nerve  was  stimulated.  About  this  time  also  I  noticed 
that  the  stomach-tube  met  with  more  resistance  in  being 
passed  down  the  pharynx,  a  condition  which  was  attributed 
to  an  improvement  in  the  reflex  tone  of  that  part,  and  a 
disappearing  of  the  relaxed  condition  of  the  pharyngeal 
walls. 


CHAPTER  VIII. 

PARTIAL  INSANITY— CHRONIC  PROGRESSIVE  DELUSIONAL 

INSANITY. 

Partial  insanity,  its  frequency  and  manifold  forms  constituting  a  large 
group  midway  between  melancholia  and  mania  —  The  use  of  the 
term  'monomania'  by  Esquirol  —  Chronic  Progressive  Delusional 
Insanity — A  well-defined  type  ;  four  stages  :  incubation,  persecution, 
grandeur,  dementia — These  described — Differential  features  :  distin- 
guished from  melancholia,  alcoholic  insanity,  and  other  groups — 
Clinical  illustrations. 

With  the  question  whether  a  man's  mind  is  ever  totally 
insane,  we  need  not  take  up  further  time  ;  but  undoubtedly 
there  is  great  force  in  the  dictum  of  Savage,  that  to  many 
cases  of  insanity,  if  not  all,  we  may  apply  the  term  insane 
persons,  meaning  thereby  persons  fundamentally  sane,  but 
more  or  less  functionally  insane.  The  terms  paranoia,  mono- 
mania, partial  insanity,  imply  this  belief,  and  a  very  great 
clinical  advantage  is  gained  by  this  recognition  of  the  fact  that 
the  old  symptomatic  group — melancholia,  mania,  dementia — 
does  not  explain  everything.  Whether  the  type  of  insanity, 
like  the  type  of  fevers,  is  changing  with  the  march  of  time, 
we  need  not  pause  to  inquire  ;  but  clinical  differentiation 
has  revealed  to  us  of  late  years  a  new  grouping  of  a  large 
proportion  of  cases  which,  under  the  older  symptomatic 
views,  were  differently  allocated. 

The  swing  of  the  pendulum  to  one  side  reveals  melan- 
cholia, to  the  opposite  side  mania  ;  but,  as  I  have  already 
stated,  in  many  cases  the  normal  state  of  feeling  is  nearly 
neutral,  and  so  also  do  we  find  it  with  many  cases  of  insanity. 
There  are  very  many  patients  who,  if  they  are  to  be  jtdged 
by  their  state  of  feeling,  are  certainly  not  cases  of  mania,  for 
they    exhibit    not    a    glimmer    of    exaltation,    nor    are    they 


126  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

melancholies,  if  loss  of  the  sense  of  well-being  and  a  distinct 
feeling  of  mental  depression  are  evidences  of  melancholia. 

They  constitute  a  large  group  midway  between  melan- 
cholia and  mania,  sometimes  partaking  of  the  one  (depres- 
sion), and  sometimes  of  the  other  (exaltation).  They  may 
be  regarded  by  any  of  the  following  names — paranoia,  mono- 
mania, partial  insanity,  all  signifying  practically  the  same 
thing.  Partial  insanity  is  a  very  wide  term,  and  it  is  possible 
to  differentiate  several  types  in  this  group ;  indeed,  to  such 
an  extent  has  this  been  done  that  our  nomenclature  has 
become  rather  confusing.  To  Esquirol  we  owe  the  term 
'  monomania,'  and  he  classified  monomanias  according  to  the 
mental  faculties  involved.  In  the  same  way  a  physician 
mav  speak  of  hepatic  disease,  cardiac  disease,  and  so  on, 
without  that  discrimination  w^hich  gives  a  clue  to  the  real 
character  of  the  disease.  If  we  are  to  strain  the  elasticity 
of  the  term  to  the  fullest  extent,  partial  insanity  or  paranoia, 
the  terms  which  I  prefer  to  use,  will  include  many  cases  of 
melancholia,  not  a  few  of  mania,  impulsive  insanity  (homicidal 
or  suicidal),  moral  insanity,  epileptic  insanity,  hysterical 
insanity,  and  the  so-called  monomanias  of  suspicion,  perse- 
cution, pride,  and  grandeur. 

In  this  chapter  it  is  intended  to  deal  chiefly  with  perverted 
sensations  and  emotions  of  suspicion  and  pride,  hallucinations, 
and  ideas  of  persecution  and  greatness,  and  this  purpose  is 
justified  by  the  fact  that  here  we  have  partial  insanity  of  the 
most  well  defined  range,  albeit  it  may  be  of  a  very  grave 
character  as  regards  prognosis.  Moreover,  this  group  is 
large  enough  to  embrace  several  varieties  essentially  different 
as  regards  origin,  mode  of  onset,  mental  characteristics,  and 
prognosis,  and  it  is  sufficiently  large  to  account  for  a  very 
considerable  proportion  of  the  cases  of  insanity  which  come 
under  medical  observation.  In  going  through  the  wards  of 
an  asylum,  we  must  be  struck  with  the  number  of  patients 
who  are  a  prey  to  suspicion,  who  believe  that  they  are  victims 
of  a  systematized  scheme  of  persecution,  who  are  subject  to 
hallucinations  of  hearing,  being  accusedand  abused- in  every 
conceivable  way,  annoyed  by  voices  in  the  walls  of  their  rooms, 
under  the  bed,  up  the  chimney,  everywhere  ;  patients  who  are 


CHRONIC  PROGRESSIVE  DELUSIONAL  INSANITY      i2j 

subject  to  strange  and  perverted  sensations,  which  they 
attribute  to  mesmerism,  electricity,  or  other  unseen  agency  ■ 
patients  insanely  proud,  and  animated  by  large  ideas  and 
lofty  delusions.  In  very  many  of  such  cases  we  will  find  the 
understanding  sound  on  every  point  outside  this  morbid  range 
of  thought,  so  much  so  that  the  idea  has  now  become  a  popular 
one  that  '  many  madmen  are  only  insane  on  one  point.' 

I  have  under  care  at  present  one  gentleman  who  is  courtesy 
and  politeness  itself,  ever  ready  and  willing  to  give  intelligent 
assistance  in  the  wards,  to  assist  the  medical  officers  in  the 
mechanical  part  of  their  investigations,  a  man  of  observation, 
who  reflects  acutely  on  affairs  at  home  and  abroad,  and  is 
only  astray  regarding  the  intention  of  one  man  towards  his 
life,  and  on  this  man  he  made  a  homicidal  attempt  which 
brought  him  to  an  asylum. 

The  confusion  which  has  so  long  obtained  regarding  the 
various  forms  of  monomania,  and  particularly  regarding  the 
manias  of  suspicion,  persecution,  unseen  agency,  and  pride 
and  grandeur,  has  been  largely  dispelled  by  the  observations 
of  Lasegue  in  1852,  and  more  especially  by  the  able  lectures 
of  Magnan  on  Chronic  Delusional  Insanity  of  Systematic 
Evolution.  These  lectures  have  been  translated  by  Dr. 
A.  Marie  and  Dr.  J.  Macpherson,  and  so  published  in  the 
American  Journal  of  Insanity  for  1895-96.  The  translation 
is  a  valuable  acquisition  to  the  English  literature  of  mental 
disease. 

Magnan  has  eviscerated  from  the  mass  a  w^ell- defined 
group  which  he  designates  chronic  delusional  insanity  of 
systematic  evolution,  and  the  main  characteristics  of  this 
group  are :  (a)  no  heredity,  or  very  slight ;  (6)  a  long,  protracted 
course;  (c)  age  of  commencement  from  thirty  onwards ; 
{d)  women  affected  four  times  as  often  as  men  ;  ie)  mental 
integrity  intact  outside  the  delusional  and  hallucinatory 
range ;  (/)  a  definite  mode  of  onset,  and  four  distinct  stages, 
viz.,  incubation,  persecution,  ambition,  and  dementia. 

On  the  question  of  hereditary  m.ental  defect  or  degeneracy, 
Magnan  observes :  '  The  victims  of  chronic  progressive  insanity 
may  undoubtedly  present  signs,  of  hereditary  degeneration 
and  of  psychical  abnormality  ;  but  similar  hereditary  nervous 


128  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

defects  are  manifested  in  general  paralytics,  simple  maniacs, 
and  mentally  well-balanced  healthy  individuals,  as  well  as  in 
the  hereditarily  degenerate.  But  although  here  and  there  in 
the  ranks  of  chronic  progressive  insanity  an  isolated  case 
of  hereditary  mental  defect  may  appear,  it  does  not  neces- 
sarily follow  that  such  is  a  hona-fide  case  of  mental  degeneracy. 
If  we  examine  the  clinical  records  of  these  cases,  we  find 
hard-working  mothers  of  families  engrossed  with  the  cares 
of  their  household  up  to  the  date  of  their  illness ;  we  meet 
with  others  in  asylums  who  possess  cultured  minds  and  a 
keen  sense  of  observation  ;  others,  again,  are  intelligent  sober 
men,  who,  as  a  rule,  have  reached  their  fortieth  year  without 
manifesting  any  mental  disorder  which  was  in  any  way 
appreciable  to  their  relations.' 

The  period  of  incubation  is  frequently  unobserved.  It  is 
marked  by  more  or  less  depression  and  anxiety  ;  there  is  no 
insanity  as  yet,  but  a  hypersensitiveness,  a  habit  of  doubt 
and  a  careful  scrutiny  of  his  sensations,  with  perplexing 
anxious  thoughts  as  to  their  why  and  wherefore.  My  ex- 
perience is,  as  Magnan  puts  it,  that  this  period  is  frequently 
unobserved,  for  the  patient  is  not  likely  to  speak  of  nebulous 
thoughts  and  suspicions ;  and  later  he  is  too  wrapped  up  in 
the  morbid  present  to  reflect  accurately  or  with  any  interest 
on  his  past,  so  that  it  is  difficult  to  obtain  data.  It  may  be, 
however,  that  a  history  can  be  obtained  from  friends,  of 
causes  for  anxiety  and  depression,  such  as  business  failure, 
or  a  dissolute  husband,  or  prolonged  anxiety  accompanied 
by  nursing  and  poverty. 

Magnan  observes  that  the  patient  has  a  general  feeling  of 
ill-being,  and  an  inexplicable  discontent  with  his  surround- 
ings, and,  in  the  case  of  females,  a  feeling  of  jealousy  is  often 
excited  by  an  absurd  or  unusual  incident.  At  this  stage  of 
the  affection  the  symptoms  which  initiate  the  malady  are, 
as  Lasegue  remarks,  only  of  relative  value.  '  There  are  no 
great  mental  disturbances,  no  marked  depression  of  spirits, 
only  some  insignificant  personal,  unpleasant  emotions. 
Until  now  the  subjective  symptoms  deserve  no  better  name 
than  petty  worries  and  annoyances,  nor  is  the  insanity  accom- 
panied by  sensory  disturbances. 


SECOND  STAGE— DELUSIONS  OF  PERSECUTION      129 

The  second  stage,  the  outbreak  of  delusions  of  persecution, 
with  perverted  sensations  and  hallucinations,  or  both,  is  well 
marked.     It  is  called  by  Magnan  the  mania  of  persecution  ; 
but,  to  prevent  misconception  afterwards,   I   use  the  term 
'  obsession  of  persecution,'  a  term   that   can   be  applied  to 
describe  a  prominent  feature  of  several   concrete   forms  of 
insanity,  and  preferable  to  persecution  mania,  \\  hich  repre- 
sents a  concrete  idea  itself.     The  fact  that  mani;:  of  persecu- 
tion is  freely  used  in  application  to  several  conditions  totally 
different  in  their  inception,  syndromata,  and  progucjsis,  makes 
it  desirable  to  give  up  the  term  altogether,  and  to  use  it  to 
describe   a  stage  of  progressive   delusional  insanity  is   mis- 
leading.    The  second  stage  is  not  an  abrupt  departure  from 
the  first  so  far  as  the  patient's  history  is  concerned ;  but  to 
the  observer,  who  knows  little  or  nothing  of  the  subjective 
experience  of  the  past,  its  onset  seems  abrupt.     It  is  still 
open  to  question  whether  perverted  sensation  is  not  the  very 
beginning  of  the  malady  ;   but  of  this  we  may  be  certain, 
that  the  second  stage  is  characterized  by  perverted  sensa- 
tions, hallucinations,  and  delusions  of  persecution.     Quoting 
freely  from  Magnan,  the  following  description  briefly  describes 
it  and  the  stages  which  follow :  At  first  the  hallucination  of 
hearing   is    not  verbal,   but    consists    of   imperfect    complex 
sounds  ;   gradually  they   develop   into   hummings,   rustlings, 
afterward  into  low  whispering  voices.     Finally,  isolated  and 
distinct  words  are  heard  in  a  loud  voice,  and  frequently  in  a 
foreign  language,  if  the  patient  knows  more  than  one  language. 
Every  auditory  impression,  of  whatever  kind,  is  sufficient  to 
produce  the  verbal  hallucination,  the  pulsations  of  the  heart, 
the  creaking  of  waggon-wheels,  the  ticking  of  a  clock,  etc. 
The  voices  may  occur  without  any  such  stimulus,  and  may 
be  heard  when  all  around  is  perfectly  still.     Hallucinations 
of  sight  are  much  less  common  ;    hence  the  m3'stery  and  the 
reason  why  some  patients  are  long  in  discovering  a  morbid 
solution  for  the  persecution  which   they  suffer.     One   man 
under   my  care   for  fifteen   years  has  not   yet  been  able  to 
identify  his   persecutors  beyond   the  word   they.     '  They  do 
this,  they  do  that ;  but  who  are  they  ?     Ah  !  that's  what  I 
can't  tell  you.'     Magnan  quotes  the  case  of  a  woman  secluded 

9 


I30  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

for  three  years  and  some  months  in  a  cell.  She  evinced 
very  distinct  visual  hallucinations.  Her  persecutor  appeared 
to  her  showing  sometimes  only  his  eyes,  at  other  times  his 
grinning  face.  In  her  case  it  is  probable  that  the  prolonged 
seclusion — he  does  not  say  how  much  of  it  was  dark  seclu- 
sion, but  probably  the  most  of  it  was — the  darkness  and 
nervous  fear  and  suggestions,  assisted  materially  in  conjuring 
these  awful  sights  of  her  morbid  imagination. 

One  of  the  most  distracting  phases  of  this  obsession  of  per- 
secution is  the  belief  that  a  man's  thoughts  are  read  while  still 
unuttered,  that  they  are  stolen.  So  distressing  is  this  idea 
that  patients  will  devise  means  to  get  away  from  the  reach 
of  their  supposed  persecutors,  only  to  find  that  they  are 
followed,  and  their  thoughts  read  before  any  move  can  be 
effected.  One  man  begged  his  brother  to  choose  for  him  a 
home,  and  not  let  him  know  where  it  was,  for  he  added,  '  If 
I  were  told  where,  enemies  would  also  be  informed,  for  they 
steal  my  thoughts,  and  would  follow  me  to  my  new  home.' 

By-and-by  the  patient  speaks  in  answer  to  the  voice, 
holding  a  dialogue  with  it,  or  it  may  be  with  two  separate 
voices  :  one  may  accuse,  the  other  reproach,  a  third  defend 
the  patient  or  act  as  censor.  '  When  the  abuse  is  funny,  the 
censor  laughs  and  mocks  ;  if  it  goes  beyond  proper  limits,  or 
if  the  censor  finds  the  expression  too  strong,  he  takes  the 
part  of  the  defender.'  The  hallucinations  are  in  many  cases 
probably  the  sequel  to  ideas,  or  at  least  suspicions,  of  perse- 
cution, and  their  character  is  determined  accordingly  by 
the  ticking  aloud,  so  to  speak,  of  such  thoughts  in  the  brain, 
what  Magnan  calls  very  appropriately  verbal  echoes.  Halluci- 
nations of  smell  are  sometimes  present  ;  the  patient  com- 
plains of  sulphur  being  thrown  on  her,  vitriol,  etc.  In  like 
manner,  there  may  be  hallucinations  of  taste  or  other  senses. 

The  disorders  of  general  sensation  can  only  be  referred 
to  in  general  terms,  for  their  manifestations  are  endless. 
According  to  Falret,  they  appear  in  the  third  stage,  but  this 
is  not  Magnan's  experience,  and  since  giving  special  atten- 
tion to  the  subject  I  am  disposed  to  endorse  his  remark  that 
these  general  sensations  may  appear  concomitantly  with  the 
hallucinations  of  hearing,  or  precede  them,  or  even  give  rise 


DISORDERS  OF  GENERAL  SENSATION  131 

to  the  ideas  of  persecution.  They  may  suggest  to  the 
morbid  perception  of  the  patient  the  creeping  of  insects  over 
the  skin,  the  sucking  of  the  breath,  the  charging  of  the  head 
with  electricity,  or  the  throwing  of  darts  on  the  body. 
Genital  sensations  are  common  in  women.  They  charge 
men  with  violating  them,  giving  them  a  loathsome  disease, 
impregnating  them,  etc. 

In  a  patient  afflicted  with  disordered  general  sensations 
and  hallucinations,  what  more  natural  than  that  ideas  of 
persecution  should  become  deeply  rooted  ?  '  The  ideas  of 
persecution  are  constantly  confirmed  by  false  interpreta- 
tions. The  patients  claim  that  they  are  constantly  watched, 
that  the  walls  of  their  houses  have  inspection-holes,  that 
their  neighbours  are  spies,'  and  so  on.  The  ideas  of 
persecution  don't  stop  here  ;  the  systematized  evolution  of 
the  disease  goes  on,  and  the  most  natural  course  in  the 
circumstances  is  for  the  patient  to  put  the  question,  and 
repeat  it  :  Why  this  persecution  ?  Who  are  they  who 
persecute  me  ?  The  answer  to  these  questions  is  determined 
by  wrong  deduction,  of  course,  according  to  the  mental 
history  of  the  individual.  Some  are  persecuted  by  secret 
societies,  by  Freemasons,  the  Oddfellows'  Society,  by 
Fenians,  Americans,  or  certain  individuals,  there  being 
usually  one  central  head,  and,  according  to  Magnan,  the 
motives  of  the  persecutors  are  as  various  as  the  persecutors 
themselves. 

One  man  believes  that  he  is  tormented  by  anarchists  for 
political  reasons,  a  woman  stated  her  opinion  that  attempts 
were  being  made  to  throw  her  into  a  lethargic  state  in  order 
that  she  might  be  violated,  and  a  man  imagines  the  aim  of  his 
enemies  is  to  render  him  insane  so  as  to  secure  command  of  his 
money.  Having  carefully  inquired  of  several  patients  afflicted 
with  this  disease,  I  find  that  a  motive  is  not  always  clear 
to  the  patient.  In  my  experience,  the  motive  is  often  as 
puzzling  to  the  patient  as  to  the  observer,  and  he  has  not 
got  beyond  the  question.  Why  are  they  doing  it  ?  In  one 
of  my  cases  the  motive  is  quite  evident  to  the  patient  ;  he 
says  he  is  being  poisoned  by  Americans,  and  he  warns  me 
that   I    am  being  poisoned  also,   and   that  their   aim   is   to 

9—2 


132  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

poison  all  the  people  in  this  kingdom,  so  that  they  may  obtain 
possession  of  the  country  for  themselves. 

In  the  logic  of  events,  there  ought  now  to  follow  a  period 
of  active  resentment.  It  seems  strange  that  a  man  or  woman 
should  be  besieged  by  ideas  of  persecution,  the  description 
of  which  is  often  so  harrowing  as  to  make  us  wonder  how 
they  have  borne  this  seeming  reality  so  long  without  striking 
out.  But  as  a  matter  of  fact  they  do  bear  it,  and  often 
fatten  on  it.  Some  of  our  patients  so  afflicted  are  plump 
and  physically  healthy ;  they  eat  well,  sleep  well,  arid  enjoy 
life  to  a  wonderful  extent.  Thus,  the  question  arises  whether 
the  oft-told  horrible  tale  with  which  the}-  delight  to  regale 
the  ears  of  every  passer-by  does  not  become  the  self-exalta- 
tion of  the  martyr.  Following  on  this,  we  may  inquire 
whether  the  real  melancholia  is  not  that  of  the  incubation 
period,  and  the  obsession  of  persecution  a  late  and  outward 
expression  with  actual  sensory  realities,  albeit  they  are  morbid 
and  produce  false  representations.  With  the  mental  dis- 
tress becoming  gradually  obliterated,  the  patient's  state  of 
feeling  becomes  adjusted  more  in  harmony  with  his  altered 
sensations.  Be  that  as  it  may,  active  resentment  is  not  so 
common  as  one  might  expect,  and,  with  all  respect  to 
Magnan,  I  am  disposed  to  believe  that  it  i's  more  frequent 
in  cases  of  the  alcoholic  insanity  of  persecution  to  be  after- 
wards described. 

The  following  description  from  Magnan's  lectures  is  quite 
compatible  with  the  mental  attitude  of  the  patient  and  his 
natural  impulses,  and,  as  it  only  refers  to  his  attempts  to 
evade  his  persecutors  and  their  persecutions,  may  be  accepted 
as  reliable.  It  is  regarded  as  of  short  duration.  '  In  order 
to  escape  from  his  persecutors  he  may  change  his  studio 
or  office  incessantly,  or  he  may  change  his  name.  Those 
who  can  afford  it  frequently  take  long  voyages  to  distant 
parts  (Foville's  migrating  insane).  Those  of  them  who 
think  they  are  being  poisoned  purchase  their  food  at  various 
shops  at  a  distance  from  their  homes,  and  prepare  it  them- 
selves for  use  with  infinite  precautions.  They  either  cook 
for  themselves,  or  frequently  change  their  eating-houses. 
They  draw  water   at   daybreak   before  "others'  have  used  it. 


THREE  MODES  OF  REACTION  133 


One  of  our  patients,  in  order  to  avoid  electrical  discharges, 
wore  stays  furnished  with  magnets,  and  silk  stockings.  Some 
have  been  known  to  commit  offences  in  order  to  be  punished, 
so  that  they  may  invoke  the  aid  of  justice. 

Three  modes  of  reaction  may  be  manifested :  one  is  to  try 
and  outwit  the  persecutors,  and  this  has  already  been  de- 
scribed, with  this  exception,  that,  instead  of  evasion  or 
running  away,  the  patient  may  still  further  exercise  his 
powers  of  circumvention  by  erecting  barricades,  stopping  up 
crevices  in  his  room  to  prevent  poisonous  fumes  penetrating. 
He  stuffs  his  nostrils,  wraps  up  his  head  to  the  verge  of 
suffocation,  or  holds  his  head  low  down  to  shelter  it  from 
darts,  with  less  reason  than  the  ostrich,  which  buries  its 
head  in  the  sands.  A  second  mode  is  by  suicide,  the  patient 
losing  heart  altogether ;  and  a  third,  and,  according  to 
Magnan,  a  most  frequent  mode,  is  the  homicidal  reaction. 
'  We  have  known  some  who  sat  in  the  staircases  of  their 
houses  all  night  with  a  lighted  lamp  and  revolver.  One  of 
our  female  patients  was  always  armed  with  a  stiletto  to 
defend  herself  against  agents  who  followed  her  so  as  to  find 
her  in  the  act  of  doing  something  wrong,'  Such  patients, 
under  the  influence  of  a  hallucination,  frequently  strike  at 
an  inoffensive  passer-by  with  an  umbrella,  or  stick,  or  knife, 
or  even  shoot  with  a  revolver,  to  the  danger  of  life. 

Then  comes  a  time  when,  failing  words  to  express  his 
meaning  and  describe  his  inward  state,  the  patient  invents 
phrases,  and  introduces  words  with  new  and  strange  adapta- 
tions. This  is, probably  more  noticeable  in  patients  of  the 
poorer,  uneducated  class,  whose  normal  vocabulary  is  of 
limited  range ;  but  educated  or  uneducated,  it  is  a  very 
noticeable  feature  of  the  disease.  One  patient  writes  a  letter 
as  follows  :  '  That  I  have  got  attraction  to  my  frame,  medical 
attraction  to  the  atmosphere  ;  that  they  are  taking  me  in 
from  Glasgow,  doing  as  I  am  and  has  done  ;  that  they  have 
controlled  me  to  mechanism,  steam,  or  wind,  gauging  of  the 
atmosphere  ;  that  I  have  controlled  my  frame  to  his  caturging 
or  rifle  pits  in  Lenzie.' 

This  man  says  there  is  a  man  in  the  moon  continually 
troubling  him  ;  that  the  sun  works  on  him,  and  is  continu- 


134  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

ally  sending  sunlight  into  his  body.  He  admits  that  he  had 
sunstroke  while  in  India  with  his  regiment,  and  seems  to 
have  committed  some  very  insane  actions  for  which  he  was 
discharged  and  sent  home.  He  sometimes  feels  a  bad  taste 
in  his  mouth,  and  suspects  it  is  due  to  poison  put  there  by 
some  of  his  enemies. 

The  following  are  expressions  taken  down  as  they  were 
uttered  by  a  female  patient  :  '  They  took  in  my  frame  in 
concealment  with  their  weapons.'  '  They  cannot  telephone 
without  a  female  frame  being  taken  in.'  '  I  didn't  come  to 
expound  the  weapons,  and  Mr.  Tennant  will  let  out  my 
frame.' 

The  third  stage  of  chronic  progressive  delusional  insanity 
is  that  of  megalomania  (mania  of  greatness),  or,  as  I  prefer 
to  describe  it,  the  obsession  of  greatness.  It  is  still  un- 
certain by  what  mental  process  the  transformation  from 
delusions  of  persecution  to  those  of  greatness  or  grandeur 
takes  place,  and  there  is  considerable  conflict  of  opinion 
still  regarding  this  point.  But  it  is  likely  that  the  change 
is  a  gradual  transformation,  and  it  is  certain  that  in  many 
cases  it  has  taken  place  for  some  time  before  it  is  suspected, 
owing  to  the  reticence  of  the  patient  on  the  subject.  The 
obsession  of  persecution  becomes  weaker  and  weaker,  and 
by  suggestion  or  hallucination  the  obsession  of  greatness 
takes  possession  in  the  patient's  mind,  strengthening  the 
morbid  process  of  grandiose  reasoning  which  has  begun  to 
take  root  in  a  mind  already  considerably  weakened  and  more 
insanely  susceptible  than  ever. 

The  following  are  examples  of  the  transformation  :  '  The 
transition  from  ideas  of  persecution  to  ideas  of  ambition  and 
grandeur  often  happens,  as  Foville  remarks,  as  a  result  of 
logical  deduction.  The  patients  imagine  that,  since  they 
have  been  unintermittently  tormented  for  many  years,  so 
much  envied,  so  intensely  detested,  they  must  be  people 
of  no  small  importance.  A  female  patient,  after  complaining 
that  her  brain  was  paralyzed,  and  that  she  was  deprived  of 
her  mental  faculties,  exclaimed  one  day,  "  If  I  were  less 
intelligent,  I  would  not  have  been  so  afflicted.  They  have 
sold  my  birthright  for  15,000  francs,  my  character  for  45,000 


THE  GRANDIOSE  PERIOD  135 


francs,  and  they  steal  my  thoughts  to  write  a  book  with." 
One  female  patient  declared  that  her  persecutor,  a  priest, 
after  many  years  changed  his  tactics,  gave  her  ^30,000,000, 
and  made  her  an  exalted  personage  in  order  that  he  himself 
might  benefit  by  her  influence.  In  certain  cases  a  halluci- 
nation suddenly  produces  the  ambitious  idea.  A  female 
patient  one  day  heard  herself  called  "  Queen  of  France." 
It  must  not  be  supposed  in  the  last  instance  that  the  change 
was  sudden,  because  the  hallucination  gave  it  birth  ;  the 
grandiose  conception  was  in  course  of  formation,  when  the 
hallucination  confirmed  it '  (Magnan). 

A  consideration  of  the  foregoing  facts  will  suffice  to  impress 
upon  you  that  to  a  mind  besieged  with  delusions  of  persecu- 
tion, but  instinct  with  egotism,  the  idea  of  retribution  or 
restitution  a  hundredfold  for  all  they  have  suffered  is  quite 
conceivable  ;  and  that  the  grandiose  conceptions  should  be 
of  an  extravagant  kind  in  some  cases  is  not  surprising  when 
we  have  regard  to  the  mental  deterioration  of  many  patients 
at  this  stage.  In  inany  cases  the  grandiose  stage  is  only 
manifest  in  self-conceit,  optimism,  and  a  vague  sense  of 
intellectual  or  other  capacity,  without  explicit  delusion. 
One  patient  evinces  it  in  her  manner  and  carriage ;  she 
looks  as  if  she  regarded  everyone  as  dirt  beneath  her  feet, 
but  as  yet  has  not  expressed  any  delusions.  Another  very 
like  the  preceding  in  gait  and  behaviour,  an  older  woman, 
calls  herself  God's  wife;  but  her  intellect  is  enfeebled,  and, 
except  in  the  way  she  comports  herself  physically,  she  does 
not  act  the  character.  She  neither  blesses  nor  bans ;  she 
gives  no  intellectual  results. 

One  question  arises  here.  Do  the  delusions  of  persecution 
and  greatness  ever  occur  together  in  the  patient,  and  is  there 
ever  a  retrogression  to  the  extent  that  a  man  lapses  back 
from  ideas  of  grandeur  to  ideas  of  persecution  ?  If  there  is 
any  see-saw,  it  must  be  taken  as  evidence  of  a  weak  inheritance ; 
although  in  chronic  progressive  insanity  we  may  have  the  two 
forms  of  delusion  at  the  same  time  without  any  see-saw  or 
suggestion  of  a  weak  inheritance.  I  believe,  however,  that 
the  two  kinds  of  delusion  may  co-exist  for  a  time  at  least,  and 
give  rise  to  some  confusion  and  doubt  as  to  the  nature  of  the 


136  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

case ;  but  though  clear  and  distinct  from  each  other,  they 
are  probably  the  result  of  one  fundamental  obsession  of 
persecution,  and  one  is  more  predominant  than  the  other. 
Indeed,  the  exalted  idea  often  appears  very  early  in  the 
second  stage,  and  in  such  a  case  there  is  no  dividing-line 
between  the  second  and  the  third  stage  at  all. 

The  fourth  and  last  stage  is  that  of  dementia,  with  all  the 
mental  powers  reduced,  and  a  condition  of  fatuity  as  the 
result.  Respecting  this  there  is  also  some  controversy,  for 
the  disease  is  said  to  last  from  twenty  to  forty  years  ;  and 
if  we  take  the  latter  period,  dementia  in  any  case  ought  to 
be  an  inevitable  result  in  many  cases  on  the  score  of  senility 
alone.  Falret,  while  admitting  a  weakening  of  intellect 
towards  the  end  of  the  grandiose  period,  and  a  more  confused 
state  of  mind,  refuses  to  acknowledge  the  existence  of  a  period 
of  dementia  as  an  essential  fourth  stage  of  the  disease.  This, 
however,  is  a  matter  of  small  moment,  for  the  tendency  of 
all  forms  of  chronic  insanity  is  towards  dementia,  just  as  the 
tendency  of  life  prolonged  is  towards  senility. 

From  chronic  progressive  delusional  insanity  we  must 
differentiate  melancholia,  subacute  or  chronic  alcoholic 
insanity,  insanity  of  adolescence,  epileptic  insanity,  general 
paralysis.  It  may  appear  a  simple  matter  to  do  this  ;  but  we 
must  remember  that  we  have  here  described  the  whole  life- 
history  of  the  disease,  extending  over  thirty  or  forty  years ; 
and  no  such  case  will  come  to  us  with  the  whole  life  history 
— past,  present,  and  future — opened  out  before  us.  The 
diagnosis  therefore  becomes  more  perplexing  in  proportion 
to  the  meagreness  of  the  history  presented  to  us.  In  melan- 
cholia the  essential  feature  is  distinct  mental  depression,  an 
unmistakable  grief;  the  melancholic  is  more  disposed  to 
accuse  himself,  not  others ;  his  delusions  are  different,  and 
persecution  has  no  place  in  his  thoughts.  He  is  more  likely 
to  give  evidence  of  bodily  causes  or  accompaniments.  Besides, 
the  genesis  and  the  manner  of  onset  of  the  disease  are  different 
in  both  cases,  and  the  mercurial  variations  of  the  melancholic 
are  in  contrast  to  the  systematic  sameness,  the  gradual  pro- 
gressive development  on  the  same  line,  of  the  mental  history 
of  chronic  progressive  insanity. 


DIFFERENTIAL  DIAGNOSIS  137 

The  insanities  of  alcoholism  and  other  toxic  conditions 
more  closely  imitate  this  disease,  especially  when  hallucina- 
tions of  hearing  and  ideas  of  persecution  are  present.  Indeed, 
the  two  may  fuse  together,  and,  grafted  on  the  progressive 
systematized  insanity,  the  alcoholic  may  accentuate  it, 
especially  by  the  intensity  of  the  hallucinations,  and  by  the 
addition  of  hallucinations  of  sight.  So  far  as  the  stage  of 
persecution  is  concerned,  the  two  may  be  almost  identical, 
and  it  may  be  very  difficult  to  differentiate  with  certainty. 
One  such  case  under  my  care  for  the  last  ten  years  was 
clearly  a  case  of  insanity  from  chronic  alcoholism  ;  he  was 
subject  to  congestive  attacks  of  the  brain,  with  stupor  and 
irritability.  These  gradually  ceased  ;  but  with  his  intellect 
clearing  up  he  manifested  delusions  of  .persecution,  the  form 
of  persecution  being  always  the  same  (galvanic  shocks),  and 
the  agent  the  same,  and  he  was  and  is  the  subject  of  halluci- 
nations of  hearing.  The  one  point  that  keeps  him  out  of 
the  category  of  chronic  progressive  insanity  is  that  he  is 
extremely  reticent,  not  from  suspicion,  though  he  is  suspicious, 
but  from  mental  confusion  and  stupidity,  and  his  condition 
is  stereotyped,  not  progressive.  In  alcoholic  insanity  you 
will  be  assisted  in  man}^  cases  by  evidence  of  toxgemic 
sequelae,  uncertain  gait,  tremors,  multiple  neuritis,  pupil 
symptoms,  etc. 

The  insanity  of  adolescence  and  of  a  still  later  period,  with 
marked  hereditary  susceptibility,  may  simulate  this  disease  ; 
but  there  is  a  very  essential  difference  between  the  two.  In 
the  adolescents,  and  others  named,  the  mere  fact  that  there 
is  a  morbid  susceptibility  to  adverse  influences,  moral  or 
physical,  that  the  mental  equilibrium  is  easily  disturbed, 
signifies  the  possibility  of  sudden  dramatic  effects  in  the 
mental  history.  There  is  noticeable  a  mercurial  tempera- 
ment, erratic  rise  and  depression,  ill-regulated,  intemperate 
flights  of  fancy,  outbursts  of  impulsive  character,  inconse- 
quent rush  of  ideas,  everything  by  turns  and  nothing  long, 
suggesting  the  question,  What  will  he  say  or  do  next  ? 
Now,  it  need  scarcely  be  said  that  this  is  in  marked  contrast 
to  the  characteristics  of  chronic  progressive  insanity  ;  but 
occasionally  the  ideas  of  persecution  may  be  more  consistent 


138  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

and  fixed,  and  you  must  then  have  regard  to  the  patient's 
age,  family  history,  personal  antecedents,  and  all  evidence 
which  can  be  obtained  of  hereditary  stigmata,  physical  and 
mental.  When  patients  of  the  adolescent  class  exhibit  delu- 
sions of  greatness,  they  are  not  consecutive  to  delusions  of 
persecution.  They  are  extravagant  and  far-fetched,  and  not 
formulated  with  any  basis  of  reason.  They  are  day-dreams, 
the  result  of  an  exalted  state  of  feeling,  and  the  patient  does 
not  act  up  to  them  intelligently.  In  chronic  progressive 
insanity  exalted  delusions  come  late  in  the  disease,  and  are 
logically  related  to  and  evolved  from  the  preceding  stage. 

In  epilepsy  ideas  of  persecution  prevail  after  fits,  but  there 
should  be  no  difficulty  in  distinguishing  such  cases.  Nor  in 
general  paralysis  of  the  i.nsane  is  there  any  risk  of  confusion, 
for  ideas  of  persecution  are  rare,  usually  associated  with  the 
ataxic  forms  of  the  disease  and  with  increasing  dementia ; 
and  grandiose  ideas  are  numerous,  and  rarely  ever  the  same 
for  two  hours  together.  Besides,  the  nervous  symptoms  will 
speak  for  themselves. 

The  prognosis  is  necessarily  a  very  hopeless  one,  and  this 
is  brought  out  most  emphatically  by  the  results  of  treatment. 
The  treatment  can  only  be  alleviative.  Various  means 
have  been  tried  to  arrest  the  disease,  but  without  avail,  for 
it  is  the  man  himself.  Intimidation  has  been  tried,  but 
surely  never  was  anything  more  foolish  than  to  try  by 
force  to  dissipate  a  fixed  delusion.  Trephining,  galvanism, 
stramonium,  and  cannabis  indica  have  been  tried,  but  with- 
out avail.  In  the  present  state  of  our  knowledge  we  must 
perforce  regard  the  man  and  his  disease  as  one,  and  death 
will  end  them  together.  It  is  possible,  however,  to  make 
his  life  less  miserable,  especially  where  there  is  a  distinct 
tone  of  melancholy,  and  in  all  cases  consideration  and  patience 
in  dealing  with  such  cases  is  most  desirable.  Negative  treat- 
ment means  doing  nothing  that  will  give  food  for  morbid 
reflection,  such  as  occult  treatment,  galvanism,  trephining, 
etc.  These  are  sure  to  suggest  some  fresh  devilry  on 
the  part  of  the  persecutors.  In  asylums,  and  such  patients 
must,  as  a  rule,  be  sent  to  asylums,  the  various  orders,  the 
routine,  the  continuous  alterations  in  the  discipline  for  the 


CLINICAL  ILLUSTRATIONS  139 

good  of  the  insane  community,  offer  many  suggestions  to 
such  patients  ;  and  with  the  best  intentions  possible  you  will 
give  offence,  but  as  far  as  lieth  in  you  do  not  wittingly  raise 
a  rock  of  offence  or  a  stumbling-block.  It  is  most  important 
to  get  them  to  work  if  you  possibly  can.  I  find  the  female 
patients  less  idle  than  the  males.  When  hallucinations  are 
painfully  annoying,  and  there  is  wasting  of  the  body  from 
this  and  sleeplessness,  bromide  of  potassium  is  sometimes 
very  beneficial.  Indeed,  when  there  is  accentuation  of  sensa- 
tion in  any  form  short  of  acute  neuralgia,  it  is  clearly  indicated. 
Tonics  are  often  helpful,  and  in  states  allied  to  melancholia 
the  indications  for  its  treatment  should  be  borne  in  mind. 

Clinical  Illustrations. 

Two  cases  placed  side  by  side  illustrate  the  real  and  the 
false  presentments  of  the  disease  : 

John  W.,  set.  27,  is  what  Magnan  would  call  a  degenerate, 
and  in  this  case  I  do  not  differ  from  him,  for  this  patient  has 
always  been  regarded  as  of  weak  intellect,  though  by  no  means 
an  imbecile.  He  is  of  nomadic  origin,  there  is  no  alcoholic 
history;  he  has  been  depressed  since  his  father  died  seven  years 
ago.  Has  always  been  excitable,  and  easily  disturbed,  easily 
offended;  lived  very  much  by  himself;  was  fond  of  reading. 
He  disturbs  the  neighbours,  calling  them  all  sorts  of  names  ; 
roams  about  during  the  night ;  imagines  everyone  is  speak- 
ing of  him  ;  hears  voices  planning  injury  against  him,  and 
sees  the  persecutors.  He  usually  sits  in  a  corner  with  his 
head  in  his  hand ;  complains  of  someone  trying  to  choke  or 
suffocate  him.  He  can't  say  who  this  '  someone '  is.  This 
is  his  chief  delusion.  Others  come  and  go  ;  e.g.,  believed  he 
was  mesmerized  so  that  harm  might  be  done  to  him.  Got 
some  work  to  do  such  as  he  had  been  accustomed  to  ;  would 
only  work  if  he  was  allowed  to  go  into  a  room  by  himself. 
Could  not  work  steadily  because  of  his  persecutors.  This 
man's  face  {vide  photograph)  is  weak.  Observe  the  lower 
half  of  the  face,  the  horizontal  ramus  of  jaw,  which  in  this 
case  is  not  horizontal,  but  nearer  the  perpendicular ;  the 
palate  is  highl}-  arched,  the  mouth  prominent  and  weak,  and 


I40  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

the  general  conformation  bad.  That  is  an  argument  against 
his  case  being  chronic  progressive  insanity,  and  quite  a 
sufhcient  one ;  but  note  also  in  the  same  scale  the  fact  that 
he  entertained  the  delusion  that  his  aunt  was  dead,  but 
when  she  was  brought  to  him  he  was  convinced  of  his  delu- 
sion. A  chronic  delusional  case  would  deny  the  aunt 
rather  than  the  delusion.  Note  also  that  the  evil  sugges- 
tions of  the  night  were  often  dispelled  in  the  daytime  by  his 
mother's  arguments.  Note  also  the  age,  and  the  absence  of 
strength  of  character  and  staying  power  in  argument. 

William  D.,  get.  38. — Has  been  going  wrong  for  at  least 
two  years.  First,  business  matters ;  became  bankrupt. 
This  was  the  stage  of  incubation.  Now  the  stage  of  perse- 
cution is  fully  developed.  He  hears  voices  and  sees  visions. 
Prefers  to  talk  alone  with  the  doctor.  Believes  himself 
persecuted ;  says,  '  I  hear  them  just  as  distinct  as  I  hear  you  ; 
they  force  my  thoughts.  If  I  think  one  thing,  they  substitute 
another.'  Perverted  sensations  :  Feels  cramped  and  drawn, 
and  sudden  relaxation  after.  Feels  his  brain  compressed, 
and  holds  his  head  tight  as  if  he  had  a  headache.  Special 
vocabulary :  '  They  have  the  power  of  working  me  through 
angles  of  movement ;  for  going  along  the  street  in  certain 
directions  I  am  allowed  to  move  freely  ;  in  other  directions 
they  restrict  me  by  cramps  in  my  legs.' 

Q.  Who  are  at  the  bottom  of  it  ? 

A.  The  Catholics  are  at  the  bottom  of  it. 

Q.  Can  you  name  them  ? 

A.  No ;  I'm  afraid.  They  sneer  at  every  thought  of 
mine. 

Q.  You  are  sure  they  are  Catholics  ? 

A.  They  have  no  power  in  themselves  but  what  is  given 
them. 

Q.  Given  them  by  whom  ? 

A.  Some  order  (mysteriously). 

Q.   What  order  ? 

A.   (still  very  mysteriously).     Freemasons. 

The  only  suggestion  of  exaltation  here  is  manifested  when 
I  put  what  he  regards,  superciliously,  as  a  question  that  a 
child  need  not  have  asked.     I   am  supposed  to  know  and 


Plate  II.— CHRONIC  PROGRESSIVE  DELUSIONAL  INSANITY. 
MONOMANIA  OF  PERSECUTION. 


PERSECnTORV    STAGE. 


GRANDIOSE    STAGE. 


PERSECUTORY    STAGE. 


J.   W.   MONOMANIA  OF  PERSECUTION 
•     AND    UNSEEN   AGEN'CV. 

7'oface  p.  140. 


PERSECUTORY   STAGE. 


CLINICAL  ILLUSTRATIONS  141 

understand  it  all  by  a  word  or  a  sign.  He  looks  superior 
and  pitifully  contemptuous  when  I  display  ignorance. 

He  looks  a  strong  man  ;  physically  he  is  robust ;  in  all 
other  respects  he  is  compos  mentis,  and  there  is  no  sugges- 
tion of  hereditary  weakness,  even  in  a  fractional  degree. 
On  the  paternal  side  there  is  a  history  of  intemperance,  and 
one  brother  is  of  neurotic  appearance.  Patient's  own  history 
is  fairly  good.  No  venereal  trouble,  no  alcoholic  or  sexual 
excess  so  far  as  we  can  learn. 

John  W.,  set.  38. — This  man  has  been  insane  for  some 
years.  He  is  a  man  of  marked  natural  ability,  and  he  knows 
it ;  of  extremely  ambitious  cast  of  mind,  with  quixotic 
visions  of  life  and  human  conduct  generally.  He  has 
numerous  projects  for  the  good  of  the  race  ;  writes  volumin- 
ously. His  unsoundness  of  mind  is  not  at  all  apparent,  for 
his  speech  appears  reasonable,  and  it  is  difficult  to  prove  at 
first  that  his  conduct  is  insane.  He  is  of  sensitive  organiza- 
tion, dignified  manner  and  mien,  with  conscientious  scruples 
and  egotism  mixed  together.  He  carefully  keeps  his  insane 
ideas  in  the  background  until  sometimes  provoked  to  give 
expression  to  them.  He  is  of  the  age  to  come  within 
Magnan's  classification,  and  .there  is  no  suggestion  of 
degeneracy  in  his  case  ;  but  he  seems  to  have  been  exalted 
for  years,  and  his  delusions  of  persecution,  his  suspicions  of 
the  true  motive  of  every  word  and  deed  of  those  in  authority, 
have  not  preceded  the  exaltation  and  egotism  which  seem  to 
be  a  primary  inherent  part  of  the  man's  character. 

Extracts  of  Female  Patient's  Correspondence. 

Mrs.  G.,  8dt.  39,  a  widow,  postmistress;  unhappy  married 
life  ;  husband  bad  and  deserted  her.  She  believes  she  was 
brought  to  the  asylum  owing  to  the  intrigue  of  a  man  named 
Gregory,  who  is  her  persecutor.  In  importuning  her  daughter 
to  get  her  removed,  she  plans  every  step  with  great  circum- 
spection, and  details  almost  the  words  to  be  used  and  the 
specious  arguments  to  be  employed.  She  even  goes  the 
length  of  telling  her  daughter  to  speak  well  of  her  father, 
and  frame  a  fictitious  story  of  their  married  life.     Gregory  and 


142  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

Burke  are  not  myths.  She  alleges  that  in  her  official 
capacity  she  detected  them  committing  frauds,  and  got  them 
imprisoned,  hence  their  persecution  of  her. 

'  Gregory  was  a  detective  who  lived  near  my  post-office. 
He  and  another  detective  named  William  Burke,  who 
died  here  three  months  ago,  were  dismissed  for  theft  and 
burglaries  by  the  Town  Clerk  of  Hallside.  Both  were  out  of 
employment  and  filled  up  a  "form"  stating  that  I  was 
insane,  and  gave  the  "form  "  to  the  Inspector  of  Poor,  who 
believed  it  to  be  true,  although  it  was  a  forgery  and  quite 
untrue.  The  "  form  "  had  written  on  it  two  Hallside 
doctors'  names,  both  forged  signatures,  and  so  the  Inspector 
of  Poor  brought  me  here,  believing  the  "  form  "  to  be  true. 
Gregory  and  Burke  brought  me  here  to  make  money,  and 
have  succeeded  in  doing  so.  Burke  is  now  dead,  but 
Gregory  still  wishes  to  stay  here  to  make  money.  Tell  Aunt 
Isa  to  do  exactly  as  desired,  and  may  Heaven  prosper  her 
visit  here,  and  may  I  get  away  next  week  !  The  Inspector 
of  Poor  already  knows  of  the  forged  "  form,"  but  believes 
that  I  am  quite  ill  and  unable  to  go  home,  which,  of  course, 
is  quite  untrue.  Gregory  gets  the  nurses  here  to  collect  cash 
from  door  to  door  for  me,  and  forges  signatures  to  show  how 
needy  and  urgent  the  case  is.  Gregory  pockets  the  cash,  and 
is  quite  well  provided  for.  ...  No  nurse  or  official  can  hear 
accurately  what  I  say,  because  Gregory's  speaking-tube  talks 
each  time  I  talk,  and  quite  obscures  my  remarks  frequently. 
At  other  times  Gregory's  requests  in  my  voice  are,  "  Please 
say  I  am  a  thief."  "Please  'visit'  to  get  my  things  from 
the  pawnshop."  "  Please  say  I  expect  a  baby."  "  Please 
say  I  am  covered  with  beasts."  I  was  once  violently  ex- 
pelled from  the  concert-room  unjustly,  the  exasperating  re- 
marks having  come  mostly  from  Varley's  speaking-tube.  ... 
Varley  hopes  to  stay  as  long  as  he  lives,  as  every  criminal 
desire  is  gratified,  and  the  officials  beg  lots  of  money  for  him 

and  pretend  they  are  begging  for  me.     Nurse  C.  from  H 

told  lies  against  me  in  H last  Saturday,  and  collected  a 

good  sum  of  money  for  Gregory  and  his  set.  She  pretended 
the  cash  was  for  me,  and  made  me  poor  indeed  to  get  good 
donations.      To  save  her  from  arrest   and  from   dismissal. 


CLINICAL  ILLUSTRATIONS  143 

and  to  screen  her  daily  and  nightly  indecent  conduct  with 
Gregory,  Nurse  C.  is  forced  to  tell  shameful  lies  to  the 
matrons  and  medical  staff  here.' 

Letter  to  her  Daughter. 

'If  Mr.  G.,  my  husband,  is  referred  to,  you  must  talk  very 
kindly  indeed  about  him.  He  was  a  successful  stationer, 
and  we  got  on  very  nicely  together.  He  always  behaved 
very  nicely.  You  were  living  in  England  during  my  married 
life,  and  did  not  know  him  very  well.  He  is  so  long  dead 
that  you  need  not  mention  him,  and  if  he  is  referred  to,  do 
not  say  a  word  against  him,  but  talk  as  above.  Do  not  give 
any  more  particulars  about  him.' 

The  following  extract  from  a  subsequent  letter  illustrates 
how  much  sanity  still  remains  in  these  cases,  and  how  a 
mother,  who  may  be  subject  to  the  most  outrageous  and 
profane  ideas,  and  be  impelled  to  the  utterance  of  the  most 
disgusting  language,  still  possesses  mental  capacity,  refine- 
ment, and  a  high  moral  and  religious  tone  : 

[Copy.] 

'  Hartwood  Asylum, 

'  November  \b,  1896. 

'  My  dear  Ella, 

'  I  hope  you  will  manage  to  read  this  letter,  as  it  is 
being  written  with  water.  One  of  the  nurses  accidentally 
overturned  the  ink-bottle,  and  then  put  some  water  in  it.  I 
am  glad  some  fresh  ink  has  been  procured,  and  that  you  will 
have  no  difficulty  now.  The  materials  to  make  a  small  bag, 
written  for  last  week,  have  not  been  sent.  Some  strong 
material  is  required  to  make  a  bag  a  little  bigger  than  a 
brush  and  comb  bag.  Two  yards  of  striped  tape  for  its  string, 
and  a  halfpenny  hank  of  sewing  thread  to  sew  it  are  also 
needed.  Send  also  twent5'-four  sheets  small  note-paper, 
twelve  envelopes,  two  Waverley  nibs,  and  one  (6d.)  bottle 
of  hair  pomade.  If  you  have  them  already  sent,  the  pomade 
can  wait  till  I  require  another  supply  of  paper.  Aunt  Isa 
need  not  come  up  at  present,  as  there  is  no  immediate 
prospect  of  release.     I  hope  grandma  and  my  faithful  little 


144  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

girl  are  keeping  quite  well.  You  do  not  seem  to  have  got  my 
last  letter,  which  is  puzzling.  I  am  still  enjoying  excellent 
health,  and  hope  you  will  remember  your  ablutions,  meals 
every  three  hours,  reading,  etc.,  as  directed  in  previous 
letters.  With  fondest  love  to  grandma  and  yourself, 
'  I  am, 

'  Ever  your  affectionate  mother, 

'J.  G. 

'  P. S.— Remember  grandma  and  me  in  your  prayers  every 
day.  Be  sure  always  to  keep  strictly  truthful,  obedient  to 
grandma  and  your  superior  officers  of  the  post-office,  humble, 
and  self-controlled  as  desired.  I  am  so  pleased  with  my 
little  girl,  and  know  that  she  attends  to  all  I  suggest.  You 
have  always  been  such  a  faithful  little  girl,  and  I  desire  you 
to  remain  so,  and  to  obey  grandma  cheerfully  in  every- 
thing. 

'J.  G.' 


CHAPTER  IX. 

MANIA. 

The  term  '  mania '  is  generic— Consciousness  affected  in  mania  in  different 
degrees — Note  must  be  made  of  the  range  of  a  patient's  conscious- 
ness, how  much  he  takes  in  of  what  is  going  on  around  him,  to  what 
extent  he  reaHzes  his  position  and  surroundings — Mania  considered 
under  the  following  heads  :  (i)  Simple  ;  (2)  subacute  ;  (3)  acute  ; 
(4)  acute  delirious  mania  ;  (5)  chronic  ;  (6)  recurrent ;  (7)  folie 
circulaire  ;  (8)  paranoia  or  monomania— Premonitory  symptoms  of 
acute  mania — Symptoms  of  the  attack,  mental  and  physical — Acute 
delirious  mania  implies  a  graver  reduction  of  consciousness — The 
other  forms  described — Clinical  illustrations  of  all  the  forms. 

Mania  {jxavia,  madness)  is  a  generic  term  which  has  been 
used  rather  loosely,  until,  like  the  word  madness,  its  English 
equivalent,  it  has  become  almost  synonymous  in  popular 
phraseology  with  insanity.  This  fact  makes  it  difficult  to 
give  a  correct  conception  of  the  limits  beyond  which  the 
term  cannot  be  applied.  The  older  conception  of  its  mean- 
ing was  'raging  madness,'  and  even  to-day  many  people 
regard  this  as  the  prevailing  form  of  mental  disease. 

In  a  previous  chapter  mania  was  contrasted  with  melan- 
cholia, and  it  may  here  be  repeated  that,  while  in  melancholia, 
as  a  rule,  consciousness  is  intensified,  and  the  patient  recog- 
nises his  identity,  in  mania  consciousness  suffers  more  or 
less,  being  reduced  or  altered,  and  the  sense  of  personal 
identity  may  be  more  or  less  obliterated.  In  some  cases 
it  may  be  quite  proper  to  say  that  the  patient  appears  lost 
to  all  consciousness  of  his  real  self,  and  the  identity  of  his 
surroundings  ;  but  in  most  cases  consciousness  and  personal 
identity  are  not  so  completely  altered  or  obscured.  That 
there  is  confusion  in   many  cases  is  evident  to  those  who 

10 


146  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

watch  the  first  signs  of  returning  insanity.  One  female 
patient  anxiously,  and  with  a  look  of  perplexity,  accosted  me 
thus  :  '  What's  my  name  ?  I  don't  know  this  place  ;  you're 
not  John  Thomson.  Is  my  name  Sarah  Graham  ?'  Sarah 
Graham,  by  the  way,  is  her  maiden  name.  Her  married 
name,  as  with  many  insane  women,  is  a  secondary  con- 
sideration. 

This  patient,  when  she  was  extremely  excited,  noisy,  and 
violent,  turning  night  into  day  with  her  yells  and  violent 
behaviour,  though  she  called  me  John  Thomson,  was  not 
unconscious  in  the  sense  that  an  apoplectic  or  syncopal 
patient  is.  Her  senses  guided  her  aright ;  but  in  the  higher 
domain  of  consciousness  there  was  confusion.  Of  mania 
more  than  any  other  form  of  insanity  it  may  be  said  that  in 
it  consciousness  is  not  logically  adjusted  to  fact,  and  the 
sense  of  personal  identity  is  at  fault.  A  patient  by  name 
John  Brown  kept  continually  crying,  '  I'm  daft  John  Brown  ;' 
but  in  spite  of  this  he  did  not  appear  to  realize  his  position 
nor  the  fact  that  a  crushed  arm  followed  by  amputation  had 
brought  on  insanity,  and  his  transfer  from  the  hospital  to 
the  asylum.  Here  consciousness  was  confused ;  the  memory 
of  his  previous  identity  was  not  impaired,  but  its  relation  to 
his  surroundings  was  not  appreciated  or  understood,  though 
he  had  a  vague  idea  that  he  was  daft.  The  confusion  of 
consciousness,  though  not  its  abolition,  is  evident  from  the 
following  talk  of  an  acute  case.  His  ideas  were  fairly  coherent, 
for  we  who  observed  him  could  seethe  connection.  While  a 
stenographer  was  taking  down  the  words  as  they  were  uttered 
the  patient's  attention  was  sometimes  fixed  on  him  ;  he  had 
a  purgative,  but  it  had  not  operated.  He  recognised  in  a 
dreamy,  superficial  way  that  he  was  in  an  asylum.  He  had 
been  in  another  asylum  before.  The  degree  of  oblivion 
was  not  marked,  though  the  excitement  was  great. 

'  I  am  delirious ;  I  am  insane.  Insanity.  Oh,  is  the 
medicine  coming  ?  Jeanie,  come  in  aside  us ;  come  in 
beside  us,  and  I  will  lie  down  upon  you,  and  I  will  lie  down 
upon  you.  See,  that  is  a  miracle.  See,  that  is  a  miracle. 
I  am  insane.  I  am  insane.  I  am  insane.  I  am  insane  ; 
but   I  want  treatment  ;   but  I  want  treatment ;   but  I  want 


MANIA  147 

treatment ;  and  then  I  am  going  to  hard  work  in  the  grounds  ; 
and  then  I  am  going  to  hard  work  in  the  grounds  ;  and  then 
I  am  going  to  hard  work  in  the  grounds.  Take  that  down, 
warders,  on  your  paper.  Jeanie,  Jeanie  ,•  oh,  do  they  mean 
to  say  that  ?  I  am  dehrious.  Take  that  down,  warders,  on 
your  paper.  Oh,  I  have  beHeved  the  Almighty,  the  Almighty, 
the  Almighty.  Oh,  the  medicine,  the  medicine,  the  medicine. 
Come,  quick  with  it.  I  know  that  I  am  down  at  times.  Oh, 
dinna  do  that.  Be  easier.  Jeanie,  Jeanie,  Jeanie,  Jeanie, 
Jeanie,  come  in  aside  us.  Claw  your  fit.  Oh,  what  a  dis- 
grace ;  oh,  what  a  disgrace  ;  oh,  what  a  disgrace  to  George  B., 
senior,  Argyle  Street,  New  Monkland.  Warders,  take  it  down 
on  note-paper,  on  the  note-paper.  I  am  insane.  Oh,  doctor, 
Jeanie,  the  medicine.  Doctor,  the  medicine,  the  sugar 
medicine,  the  sugar  medicine,  the  sugar  medicine.'  (The 
medicine  was  sweet.)  '  Home.  Insanity.  Insanity.  Insanity. 
The  medicine.  Jeanie.  I  am  insane,  but  I  want  to  go  to 
hard  work  after  I  get  treatment.  Warders,  warders,  take 
note  of  this,  take  note  of  this,  take  note  of  this.  Doctor, 
take  note  of  this.  I  am  insane,  as  insane  as  a  hatter  ;  but  I 
want  to  go  to  hard  work  ;  but  I  want  to  go  to  hard  work. 
Oh,  dinna  do  that ;  oh,  dinna  do  that ;  oh,  everything  is 
over  for  the  morning.  I  am  insane ;  I  am  insane,  Mr.  A. 
I  am  falling  asleep ;  I  am  falling  asleep.  It  is  the  deliriums ; 
it  is  the  deliriums  ;  the  bees,  the  bees  in  my  head.  Oh, 
dinna  kill  us  ;  oh,  dinna  kill  us.  Ay,  I  want  medicine,  the 
medicine,  the  medicine.  Saviour,  I  am  a  madman.  See 
this  man.  No,  I  am  only  shamming.  Oh,  be  kind  to  us. 
Oh,  doctor,  the  bees  are  gone  away.  Go  away.  Doctor, 
they  have  been  cruel  to  us.  Oh,  dinna  do  that,  Mr.  Anderson  ; 
dinna  do  that,  Mr.  Anderson.  I  am  grieved.  The  bees 
have  gone  away.  The  medicine  is  working.  I  was  only 
shamming  when  I  mentioned  the  pot,  the  water-closet.' 

In  mania  there  may  be  general  mental  disorder  and  excite- 
ment ;  but  in  its  individual  characters  there  is  endless  variety. 
The  explosion  may  be  intermittent,  or  prolonged  with  only 
slight  remissions.  A  man  may  know  his  own  name,  and 
the  names  of  those  about  him,  and  yet  spit  in  the  face  of 
his  friends,  shower  on  them  torrents  of  abuse,  and  defile  the 

10 — 2 


148  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

atmosphere  around  him  with  the  most  filthy  and  obscene 
language  conceivable.  He  may  consciously  commit  immoral 
acts,  knowing  them  to  be  immoral  and  wrong,  and  yet  preach 
with  all  the  fervour  of  an  evangelist.  He  may  exhibit  a 
maniacal  bent  in  one  particular  direction  without  general 
mental  derangement. 

Loss  or  diminution  of  self-control  combined  with  intensity 
of  feeling,  thought,  and  action,  are  the  leading  features 
of  mania.  When  the  mental  activities  override  volition, 
an3'thingis  possible  in  the  way  of  insane  speech  and  conduct. 

Let  me  repeat,  then,  we  must  have  regard  to  the  degree 
and  character  of  the  man's  consciousness  of  himself  and  of 
others,  of  his  position  and  his  surroundings.  You  must  also 
test  his  self-control,  and  make  note  of  his  other  mental 
processes — how  much  they  are  subverted  or  exaggerated. 
The  dement  or  the  stuporose  patient  exhibits  diminished 
consciousness ;  but  in  mama  it  is  different  :  the  excessive 
and  disordered  mental  activity  is  accompanied  by  an  erratic, 
dream-like  consciousness,  which  may  be  quickly  responsive 
to  some  stimuli,  but  not  to  all. 

If  for  a  moment  we  turn  aside  to  compare  the  sleeping 
and  the  waking  states,  the  ebb  and  flow  of  mental  dissolu- 
tion and  evolution,  a  clearer  conception  of  maniacal  con- 
sciousness will  be  possible.  We  regard  sleep  as  the  one 
extreme,  implying  an  absolute  negation  of  everything  mental, 
and  reduction  to  the  lowest  possible  limit  of  life's  functions. 
Perfect  sleep  may  be  described  by  negatives — no  conscious- 
ness, no  dreams,  no  sensation,  no  external  movement.  The 
other  extreme,  the  waking  state,  is  made  up  of  positives — 
conscious  life,  mental  activities,  the  whole  machinery  of  life 
in  motion,  the  will  presiding  and  directing  every  conscious 
movement,  a  purpose  in  this,  that,  and  everything.  Between 
these  two  extremes  there  are  shades  and  degrees  of  conscious- 
ness and  mental  activity — the  dreamy  state,  somnambulism, 
delirium,  mania;  and  the  greater  the  delirium  in  mania,  the 
greater  the  reduction  of  consciousness,  as  when  we  say  that 
a  man  is  oblivious  of  everything. 

Mania  may  be  seen  in  any  of  these  forms  :  (i)  simple,  a 
mild  ebuUition ;    (2)  subacute  ;    (3)  acute ;  (4)  acute  delirious 


MANIA  '  149 

mania ;     (5)    chronic ;     (6)    recurrent ;     (7)    folie    circulaire  ; 
(8)  monomania  (paranoia  or  partial  insanity). 

Simple  Mania. 

Simple  mania  is  difficult  to  describe,  because  it  is  so  elusive 
in  its  manifestations.  It  is  often  seen  in  asylums  as  a  mild 
ebullition  in  chronic  cases,  and  it  sometimes  brings  men 
and  women  into  asylums  who,  on  admission,  appear  to  be 
perfectly  sane.  One  such  case  was  admitted  recently,  a 
woman  who  had  some  drink,  got  noisy  and  quarrelsome, 
abused  her  husband,  committed  a  breach  of  the  peace,  and, 
having  been  certified,  was  sent  to  the  asylum.  By  the  time 
she  reached  it,  no  medical  man  could  possibly  certify  her  ; 
the  mania  had  passed  off. 

But  without  drink  to  account  for  it  at  all,  men  and  women 
of  susceptible  mental  organization  may  be  thrown  off  their 
balance,  and  their  character  and  disposition  altered  for  the 
time  being.  Unduly  elated,  excited,  ready  to  extend  the 
hand  of  friendship  to  the  stranger,  and  to  speak  out  their 
minds  with  insane  frankness,  they  are  yet  with  difficulty 
certified  insane,  and  it  is  not  always  desirable  that  they 
should  be.  Such  attacks  are  often  episodes  in  their  lives 
which  come  and  go  quickly,  and  are  soon  forgotten. 

Acute  and  Subacute  Mania. 

There  is  no  dividing-line  between  acute  and  subacute, 
and  while  a  description  will  now  be  given  of  acute  mania,  it 
must  be  regarded  as  approximate,  because  there  are  neces- 
sarily degrees  and  variations.  As  a  rule,  there  is  a  brief 
premonitory  attack  of  mental  depression,  and  the  history  of 
physical  disorder.  The  onset  is  usually  gradual,  but  may 
apparently  be  sudden. 

Sleeplessness  is  a  frequent  precursor  of  the  attack  ;  there 
may  be  a  history  of  indigestion  or  constipation.  Mental 
causes,  worries  and  anxieties,  often  react  injuriously  on  the 
physical  health,  which  in  turn  tells  upon  the  mind.  Over- 
work is  often  a  precursor,  and  acts  in  the  same  way.  There 
is    usually   noticed    besides    sleeplessness,  indigestion,    con- 


ISO  CLINICAL  MANUAL  OF  MENTAL  DISEASES 


stipation,  extreme  irritability  and  impatience  of  the  most 
gentle  and  considerate  control  ;  also  great  restlessness,  a 
disposition  to  be  always  on  the  move.  Sometimes,  however, 
the  excitement  may  take  the  form  of  prolonged,  exhausting 
study,  or  we  may  have  mania  springing  directly,  as  by  a 
rebound,  from  a  state  of  silent,  motionless  depression. 

Mental  Symptoms. — i.  There  is  considerable  excitement, 
which  may  rise  and  fall  in  its  intensity,  but  which,  as  a  rule, 
is  fairly  continuous  day  and  night.  According  to  the  amount 
of  excitement  is  the  sleeplessness  of  the  patient.  This  excite- 
ment is  not,  as  a  rule,  induced  and  kept  up  by  any  predominant 
idea  or  feeling  (except  perhaps  in  alcoholic  mania).  As  a 
rule,  it  is  indeterminative.  The  patient  talks,  shouts,  whistles, 
dances,  sings,  anything  to  make  a  noise. 

2.  He  is  a  creature  of  impulses — like  a  flash  there  comes 
whizzing  a  soup-plate,  cup  and  saucer,  or  tumbler,  or  some- 
thing more  lethal  in  the  shape  of  furniture ;  the  windows 
are  smashed  with  fiendish  delight,  or  a  violent  onslaught  is 
made  without  warning.  The  manner  and  degree  of  impulsive 
excitement  varies  ;  it  may  come  in  gusts,  the  result  of  sensory 
disturbance — the  sound  of  a  door,  the  noise  of  a  footstep,  or 
a  voice  real  or  imaginary.  Irregular  outbursts  of  excitement 
are  often  due  to  peripheral  stimuli,  hallucinations,  or  insane 
suggestions.  An  insane  suggestion  was  that  which  came 
into  the  mind  of  a  maniac  on  observing  a  finger  which  had 
lost  its  nail  from  previous  injury.  He  yelled  and  got  furious, 
and  made  as  if  to  escape  from  the  devil,  who,  he  asserted, 
had  '  clawed  off'  the  nail.  The  maniacal  excitement  may  be 
of  a  religious  character  throughout,  or  we  may  notice 
patients  evincing  religious  concern  premonitory  to  an  attack 
of  acute  mania.  The  religious  ideas  may  be  inconsistent ; 
they  may  illustrate  a  most  bewildered  state  of  religious  exal- 
tation and  invocation  with  no  real  basis  of  consciousness 
underlying  it. 

3.  The  patient's  mind  may  be  a  wilderness  of  incoherence  ; 
but  the  degree  of  incoherence  varies  in  different  cases,  and 
in  the  same  patient  at  different  times.  The  association  of 
ideas  is  usually  jerky  and  erratic,  and  some  patients  are 
mentally  boiling   over   with    old   recollections  which    come 


MANIA  ^51 

away  in  their  speech  in  a  rapid,  continuous  stream.  Here 
the  loss  of  self-control  is  most  lamentable,  for  much  is  said 
that  wounds  others,  and  many  things  are  said  that  the  sane 
mind  would  never  utter.  One  middle-aged  patient  met  during 
exercise  day  after  day  a  young  girl  well  known  to  her  ;  but 
she  was  too  oblivious  and  incoherently  delirious  at  first  to 
take  notice  of  her.  As  the  incoherence  lessened  and  the 
faculty  of  attention  was  being  restored,  she  one  day  noticed 
this  girl,  now  convalescent  from  her  third  attack,  and  exceed- 
ingly sensitive,  and  cried  out,  to  her  extreme  annoyance, 
'  Mollie  B.  was  always  daft,  Molhe  B.  was  always  daft.' 
In  vino  Veritas  is  not  more  true  than  that  the  truth  will  out 
without  mercy  or  compunction  in  acute  mania,  and  this  is 
one  of  the  most  distressing  ■  remembrances  when  recovery 
is  assured,  if  recollection  of  the  events  of  the  attack  is  not 
obliterated. 

4.  The  patient  may  give  expression  to  delusions ;  he  is 
frequently  morbidly  angry  and  suspicious ;  but  the  delusions 
are  often  of  an  exalted  character,  although  by  no  means 
always.  They  are  often  utterly  irrational  and  inconsequent. 
Among  the  insane,  as  in  chronic  delusional  insanity,  delusions 
often  take  root  by  a  seemingly  logical  process  ;  but  in  acute 
mania  they  are  often  mere  insane  suggestions  and  fleeting 
in  character.  One  man  declares  that  he  is  going  to  see  the 
Queen,  and  '  take  down  all  the  big  bugs,'  and  never  repeats 
the  notion  again  ;  it  is  an  insane  threat  more  than  a  delu- 
sion. Another  said  one  day  that  he  was  engaged  to  the 
Princess  Beatrice,  the  next  that  he  had  married  the  Princess 
AHce,  and  that  Disraeli  was  his  father.  One  young  man 
said  he  was  inspired  by  God  to  make  such  statements  as 
this,  '  God  shall  arise  and  terribly  shake  the  earth,'  and 
described  himself  as  '  a  man  of  sorrows  and  acquainted  with 
grief,'  which  in  his  case  was  the  expression  of  a  mere  vain- 
glorious religious  sentiment.  This  same  young  man  combined 
exalted  ideas  with  a  very  suspicious  nature.  It  is  always 
interesting  to  trace  the  genesis  of  delusions,  and  in  this  case 
it  was  observed  that  what  might  be  described  as  a  delusion, 
viz.,  that  he  believed  he  was  next  to  Christ,  was,  as  he  after- 
wards expressed  it,   a  mere    exaggeration  of  his  feeling  of 


152  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

goodness,  which  by  reiteration  grew  into  an  exalted  concep- 
tion of  himself. 

Another  young  man  asserted  that  he  was  'John  V.  Vande- 
leur ' ;  declared  that  he  had  come  to  his  castle,  and  called 
for  wine.  Others  evince  delusions  of  identity,  and  con- 
ceive violent  antipathies  to  certain  persons.  It  is  quite 
consistent  with  exalted  delusions  that  the  patient  should  be 
very  violent,  especially  if  he  is  so  far  conscious  as  to  try  and 
act  up  to  his  exalted  ideal,  and  is  contradicted  and  interfered 
with.  In  a  great  many  cases,  however,  the  delusions  are  not 
so  pronounced  ;  they  are  ill-formed,  fugitive  and  fleeting. 

5.  Hallucinations  are  not  infrequent  in  acute  mania,  and 
they  may  accentuate  the  state  of  excitement  or  the  impulse 
to  violence.  They  may  be,  and  often  are,  of  a  pleasing 
character,  being  often  the  mere  ticking  aloud,  so  to  speak,  of 
the  patient's  own  exalted  suggestions.  If  they  are  variable 
and  fleeting,  they  are  of  no  grave  significance.  They  are 
usually  hallucinations  of  sight  or  hearing. 

6.  The  state  of  feeling  in  mania  determines  to  a  considerable 
extent  the  character  and  course  of  the  disease.  It  has  been 
already  said  that  there  may  be  exaltation  or  suspicion,  to 
which  must  be  added  anger,  love,  fear.  It  is  always 
well  to  observe  which  of  these  exists  or  predominates.     One 

patient    vituperates   all    day,    '  Ye    b whores,  ye    d-- — 

murderers,'  and  kicks,  struggles,  and  scratches  viciously  at 
all  well-meant  attempts  to  wash,  dress,  or  feed  her.  Another 
is  amorous,  and  tries  to  hug  or  kiss ;  while  another,  from 
insane  fear  or  dread  of  she  knows  not  what,  shouts  in  order 
to  exorcise  the  unspeakable  thing,  or,  being  afflicted  also 
with  hallucinations,  makes  fierce  efforts  to  escape,  or,  turning 
round,  tries  to  rend  the  imaginary  foe  or  to  pulverize  it  with 
some  lethal  weapon. 

When  the  patient  is  exalted,  this  can  be  seen  more  in  her 
conduct  than  in  the  expression  of  delusions.  One  young 
girl  is  described  as  affecting  a  very  dignified  carriage,  reciting 
poetry  with  dramatic  voice  and  gesture,  and  being  vain  and 
absurdly  magnificent  in  her  toilet.  Eroticism  is  sometimes 
manifested,  and  often  leads  to  indecent  exposure  in  males  as 
well  as  females.     Anything  improper  is  always  a  temptation. 


MANIA  153 

and  the  mere  suggestion  is  enough  to  produce  indecencies  of 
speech  or  conduct. 

7.  It  need,  perhaps,  scarcely  be  said  that  the  moral  sense  is 
obscured  or  perverted  for  the  time  being  in  acute  mania.  It 
would  appear  sometimes  as  if  the  patient  were  fully  conscious 
that  he  was  doing  wrong  ;  and  much  is  done  from  pure 
cussedness,  to  annoy  and  irritate  others.  The  acute  maniac 
is  destructive  of  clothing,  bedding,  and  furniture  ;  micturates 
or  defsecates  on  the  floor,  steals  what  he  can  lay  hands  on, 
exposes  his  person,  and  in  his  language  gives  evidence  also 
that  he  has  no  regard  for  decency  whatever. 

8.  Faculty  of  Inhibition. — This  varies  in  different  cases,  and 
so  also  does  the  faculty  of  attention,  but  they  are  rarely 
absolutely  lost  in  ordinary  acute  mania.  One  patient,  who 
had  been  an  asylum  nurse,  and  knew  well  the  routine  of 
asylum  work,  would  moderate  her  excitement  when  the 
doctor's  visit  was  due,  and  break  out  into  additional  violence 
when  it  was  over.  Hers  was  a  good  example  of  double 
consciousness,  sane  and  insane :  the  habits  of  asylum  discipline 
were  not  altogether  lost,  and  there  was  evidence  that  her 
old  identity  was  not  quite  forgotten  ;  while,  on  the  other 
hand,  the  delusion  expressed  that  she  was  the  daughter  of 
an  M.P.  was  an  idea  in  striking  contrast,  so  that  she  was 
savagely  intolerant  of  the  nurses  and  their  uniform.  The 
sight  of  these  was  an  implied  reproach,  a  mockery  of  her  pre- 
tended exalted  position,  and  naturally  she  scowled  on  the 
nurses. 

The  Physical  Conditions  in  Acute  Mania. — These  are  deter- 
mined to  some  extent  by  the  particular  constitution  and 
previous  habits  of  the  individual,  and  any  description  which 
aims  at  precisely  enumerating  the  somatic  conditions  should 
be  received  with  reservation,  for  while  general  statements 
may  correctly  be  made,  the  various  examples  of  acute  mania 
have  constitutional  peculiarities,  and  react  in  different  ways 
to  the  mental  disturbance. 

The  Circulation. — In  many  cases  of  limited  acute  mania 
there  is  very  little  increase  in  the  pulse  rate,  and  the  heart's 
action  is  not  excessive  ;  but  in  the  most  extreme  cases,  and 
especially  in  delirious  types,  the  circulation  is  very  appreci- 


154  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

ably  excited.  The  pulse  is  usually  one  of  high  tension,  but 
it  may  be  small  and  wiry. 

The  temperature  is  rarely  as  high  as  loo",  frequently  about 
99°,  unless  there  are  complications  ;  but  often  disorder  of  the 
primcB  vice  raises  the  temperature,  and,  combined  with  a  costive 
state  of  the  bowels,  may  send  it  up  to  102"  or  more. 

The  Secretions. — i.  The  skin  is  usually  dry;  but  profuse 
perspiration  is  not  uncommon,  especially  where  restraint  is 
resorted  to.  Sometimes  the  sebaceous  secretion  is  excessive, 
and  an  offensive  odour  is  engendered  by  its  accumulation. 

The  urine  is  of  normal  quantity,  and  in  women  with 
hysterical  symptoms  may  be  in  excess.  It  is  scanty,  high- 
coloured,  and  of  high  specific  gravity  in  acute  febrile  con- 
ditions. 

2.  PrimcB  Vice. — There  is  usually  abundance  of  saliva,  except 
in  very  acute  cases,  when  the  lips  and  gums  become  dry,  the 
teeth  covered  with  sordes,  the  tongue  baked  and  cracked. 
In  some  cases  the  saliva  is  viscid  and  scanty,  the  watery 
elements  being  deficient.  The  fauces  and  pharynx  are 
frequently  covered  with  glutinous  mucus,  and  sometimes 
they  are  very  dry.  In  such  cases  refusal  of  food  from 
delusion  or  anorexia  is  noticeable,  and  the  passage  of  the 
stomach-tube  is  more  difficult  than  usual.  The  gastric 
secretion  may  be  deficient  or  normal,  and  as  a  rule  there  is 
a  tendency  to  biliary  disorder.  Constipation,  from  deficient 
mucus  secretion  of  the  intestinal  walls  or  deficient  peristalsis, 
may  be  a  prominent  symptom,  though  regular  action,  indeed 
overaction,  of  the  bowels  is  sometimes  observed. 

Appetite  and  Digestion. — The  appetite  may  be  capricious, 
or  voracious,  the  patient  bolting  his  food  ;  but  there  are  cases, 
as  already  recorded,  where  refusal  of  food  is  a  grave  symptom, 
and  where  artificial  feeding  may  be  necessary.  The  tongue 
is  frequently  furred,  and  digestion  is  often  impaired.  It  is 
of  the  greatest  importance  to  have  the  patient  frequently 
weighed,  and  to  maintain  his  strength  and  condition  by 
attention  to  alimentation  and  sleep. 

The  complexion  is  frequently  sallow,  but  sometimes  flushed, 
and  sometimes  greasy,  especially  the  forehead,  and  this 
particularly  in  alcoholic  cases. 


MANIA  155 

Sensation. — This  varies  in  different  individuals.  It  may  be 
accentuated  at  first,  but  soon  there  is  diminished  sensibihty, 
sometimes  perversion,  and  not  infrequently  indifference  to 
wounds  or  injuries,  and  even  attempts  at  self-mutilation. 

Reflexes. — These  are  usually  exaggerated ;  but  there  is  no 
certain  rule. 

Sleep,  as  previously  mentioned,  is  a  very  deficient  and  un- 
certain quantity.  It  may  be  entirely  lost,  and  when  a  good 
sleep  is  obtained  for  the  first  time,  it  is  rarely  followed  by  any 
considerable  cessation  of  excitement,  though  frequently  there 
is  noticeable  a  lucid  pause  on  waking,  which  is  soon  succeeded 
by  a  return  of  excitement.  This  is  rather  disappointing,  but 
it  is  not  by  any  means  a  bad  sign. 

Menstruation. — It  must  be  remembered  here  —  and  the 
statement  applies  to  mental  disease  generally — that  menstrua- 
tion is  a  factor  to  be  reckoned  with  in  female  cases.  It  is 
frequently  absent  in  acute  mania,  but  when  present  it 
exercises  a  potent  influence  on  the  severity  and  character  of 
the  attack,  and  very  impulsive  attacks  are  common  at  this 
period.  The  patient  is  at  this  time  more  likely  to  be  violent 
and  destructive,  and  loss  of  all  sense  of  decency  is  most 
noticeable. 

Acute  Delirious  Mania. 

Acute  delirious  mania,  by  some  called  typhomania,  implies 
a  graver  reduction  of  consciousness.  The  physical  conditions 
are  more  serious,  the  secretions  are  arrested,  the  lips,  mouth, 
tongue,  and  fauces  dry,  with  sordes  on  the  teeth  and  gums. 
The  skin  is  dry  and  sallow,  but  the  cheeks  are  often  flushed, 
the  eyes  are  sunken,  and  frequently  have  a  stony  stare. 
Motor  unrest  and  purposeless  excitement,  jactitation,  and 
fumbling  with  the  bedclothes,  are  very  conspicuous  symptoms. 
The  mania  is  so  oblivious  as  to  become  a  delirious  frenzy, 
without  any  apparent  spark  of  consciousness :  the  inco- 
herence is  extreme ;  and  the  faculty  of  attention  may  no 
longer  respond  to  outward  stimuli,  although  I  have  known 
an  extreme  case,  passing  into  a  moribund  state,  cease  her 
ravings  and  fix  her  eyes  on  the  doctor  who  was  discussing 
her  mental  condition  in  her  presence. 


156  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

Chronic  Mania. 

Chronic  mania  is  the  continuation  of  the  disease  in  a  sub- 
acute form.  It  is  not  infrequently  a  sequel  to  the  acute 
form,  for  although  the  percentage  of  recoveries  is  high,  death, 
dementia,  chronic  and  recurrent  manias,  account  for  the 
ultimate  results  in  many  of  the  cases.  In  chronic  mania 
there  is  a  certain  amount  of  normal  consciousness,  an  ability 
to  fix  attention  on  things,  and  a  certain  measure  of  self- 
control,  which,  however,  ebbs  and  flows ;  but  there  is  notice- 
able distinct  mental  enfeeblement  in  one  direction  or  another, 
and  the  memory  in  many  cases  is  more  or  less  impaired. 
As  a  rule,  the  physical  health  is  fairly  good,  and  in  the  work 
of  the  asylum — farm,  garden,  etc. — much  excellent  help  is 
given  by  such  patients.  One  case,  a  female,  does  well  in  the 
laundry,  singing  loudly  and  harshly,  and  joking,  and  some- 
times dancing,  yet  all  the  time  attending  to  her  work.  She 
has  acute  perceptions  of  what  is  going  on  around  her,  and 
her  memory  is  good  ;  but  her  language  is  tainted  with  wicked 
sexual  suggestions,  and  exaltation  and  sexual  suspicion  are 
the  predominant  characters  of  her  mental  state.  It  must 
be  remembered  that  here  the  normal  individuality  is  more 
manifest,  because  sanity  is  not  entirely  overthrown,  and 
therefore  there  is  much  more  rational  diversity  of  symptoms 
in  the  role  of  chronic  mania. 

Recurrent  Mania. 

Recurrent  mania  is  more  intense  and  oblivious  while  it 
lasts,  and  more  resembles  acute  mania  than  chronic  mania. 
The  maniacal  attacks  are  often  as  acute  as  we  see  them  in 
acute  mania ;  but  there  are  intervals  of  quietness  between^ 
and  often  lucid  periods  intervening,  during  which  the  patient 
is  to  all  intents  and  purposes  sane.  Recurrent  mania  is  not 
uncommon  in  asylums,  and  when  we  remember  that  all  our 
lives  have  their  ph3^siological  vicissitudes,  their  cycles  of 
periodicity,  it  is  not  surprising  that  unstable  brains  should 
have  these  changes — an  ebb  and  flow  of  mental  excitement 
—more  intensely,  and  be  more  liable  to  mental  failure  and 
exhaustion. 


MANIA  157 

FOLIE    CiRCULAIRE. 

Folie  circulaire  is  another  example,  and  a  very  striking 
one,  of  the  tendency  to  periodicity  in  mental  disease.  Our 
first  conceptions  of  circular  insanity  are  due  to  Falret  and 
Baillarger,  and  the  idea  contained  in  the  name  folie  circulaire 
gives  the  nature  of  the  disease  in  a  nutshell,  for  circular 
periodicity,  with  its  regularly-recurring  phases,  is  the  essential 
character  of  the  disease.  It  is  more  frequently  observed 
among  the  middle  and  upper  classes,  and  where  it  is  dis- 
covered among  poorer,  less  educated  patients,  it  does  not 
give  out  the  same  brilliant  morbid  scintillation  of  mental 
aberration  that  strikes  an  observer  in  the  wards  of  an  asylum 
for  paying  patients.  The  same,  of  course,  is  true,  but  in  a 
less  degree,  of  all  forms  of  acute  insanity  :  The  greater  the 
intelligence  and  education,  the  greater  the  power  and  range 
of  intellectual  expression  and  imagination.  My  experience 
of  this  disease  was  larger  at  Morningside  among  private 
patients  than  it  has  been  since ;  but  this  fact  has  struck  me 
several  times  among  the  poorer  classes,  that  when  it  shows 
itself  in  their  midst  it  is  frequently  as  a  sequel  to  the 
melancholia  of  the  climacteric  period. 

The  course  of  folie  circulaire  resembles  the  course  of 
epileptic  insanity  in  this  respect,  that  the  mental  changes, 
the  ideas,  the  character  and  conduct  of  each  phase  is  very 
similarly  reproduced  in  the  same  phase  when  it  recurs  again 
and  again.  Excitement,  depression,  and  insanity  are  the 
three  phases  of  the  circle.  The  circle  may  be  long  or  short 
in  different  individuals,  and  may  be  completed  in  three 
months,  or  not  for  more  than  a  year.  In  the  first  or 
maniacal  stage  there  is  frequently  apparent  marked  egotism 
and  vanity.  The  patient  affects  the  air,  manner,  and  dress 
of  the  youth.  An  old  woman,  a  widow,  with  a  grown-up 
family,  conceives  an  insane  amorous  attachment  for  a  young 
man.  Another  shows  it  in  her  dress,  and  her  ideas  of  what 
is  becoming  in  her  millinery  adornments.  One  man  always 
begins  with  an  exhibition  of  his  Goliath-like  strength,  which 
is  a  most  insane  exaggeration,  as  he  is  a  very  commonplace 
athlete.     He  offers  to  fight  any  six  men,  and  is  most  rude 


158  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

and  abusive.  It  is  interesting  to  watch  the  several  stages  in 
the  evolution  of  the  maniacal  outburst  from  the  first  initial 
symptom,  which  may  be  in  a  matter  of  toilet,  as  in  arranging 
his  necktie  or  in  the  careful  parting  of  the  hair.  During  this 
stage,  as  in  all  maniacal  states,  there  is  a  tendency  to  lose 
weight,  though  some  patients  may  thrive  on  it  if  they  sleep 
and  eat  well,  losing  weight  sometimes  in  the  depressed 
melancholic  state  which  follows.  As  a  rule,  however,  the 
time  when  the  patient  gains  weight  is  rather  in  the  quiet 
stage. 

The  melancholic  state  is  sometimes  a  mere  reaction,  though 
it  may  be  exaggerated  by  painful  reflections  on  the  absurd 
and  incongruous  behaviour  of  the  previous  stage  of  mania 
and  exaltation.  Cases  are  not  infrequent  where  the  sober 
mind,  moved  by  a  feeling  of  depression,  reflects  with  miser- 
able persistence  on  the  extravagances  of  the  previous  weeks 
or  months,  and  a  deepening  depression  ensues,  often  quiet 
and  self-contained,  but  none  the  less  acute.  In  some  cases 
suicidal  promptings  may  arise,  and  it  is  well  to  be  on  guard. 
The  stage  of  mental  equilibrium  is  not  always  well  marked, 
and  as  the  disease  progresses  it  diminishes,  and  dementia 
takes  its  place.  Indeed,  it  becomes  difficult  at  last  to  dis- 
criminate between  the  melancholia  and  dementia  of  the 
latter  end  of  this  disease. 

Folic  circulaire  is  by  some  regarded  as  a  disease  which 
comes  on  usually  in  the  adolescent  period  ;  but  although  it 
is  true  that  thus  early  alternations  of  m.ania,  melancholia  and 
stupor  are  common,  especially  in  patients  with  insane  in- 
heritance, these  phases  are  usually  erratic  and  unsystematic 
in  the  order  and  manner  of  their  appearance,  and,  as  I  have 
already  observed,  the  climacteric  period  is  as  likely  to 
originate  true  folic  circulaire.  We  have  it,  however,  on  the 
authority  of  Clouston,  who  enters  very  fully  into  this  subject, 
that  it  has  occurred  in  his  experience  from  the  age  of  fifteen 
to  seventy-four.  His  experience  is  that  with  one  exception 
it  came  on  during  the  actively  sexual  period  of  life.  Clouston 
believes  that  in  go  per  cent,  folie  circulaire  is  a  sequel  of 
maniacal  excitement. 


MANIA  J  59 

Monomania. 

Monomania. — This  has  already  been  referred  to  under  the 
head  of  chronic  delusional  insanity.  It  is  synonymous  with 
partial  insanity.  It  is  held  by  some  that,  apart  from 
particular  delusions,  the  patient's  mental  integrity  is  intact. 
Dr.  Bannister,  of  the  Kankakee  Asylum,  Illinois,  holds 
'  that  there  may  be,  and  are,  cases  in  which  a  single  delusion 
or  imperative  conception  forms  the  whole  of  the  insanity 
either  at  one  of  its  stages  or  during  its  whole  course.'  This 
may  be  too  exclusive  a  statement  ;  but  in  the  main  Dr. 
Bannister  is  right,  and  there  certainly  are  limitations  of 
mental  integrity,  which  justify  the  term  'partial  insanity.' 
Under  this  title  comes  the  monomania  of  pride,  which  is 
not  a  later  evolution  of  the  chronic  progressive  delusional 
insanity,  but  a  gradual  development  from  pride  and  vanity 
characteristic  of  youth,  and  often  associated  with  a  too 
frequent  worship  of  self  in  the  looking-glass  and  at  the 
shrine  of  the  milliner  or  tailor. 

Paranoia  is  a  term  freely  used  in  Germany  and  America, 
but  not  much  adopted  in  this  country.  It  is  used  in 
Germany  as  synonymous  with  verrucktheit  (mental  derange- 
ment). No  matter  what  may  be  the  etymology  of  these 
words,  paranoia  is  used  to  designate  mental  disease  of  a 
systematized  delusional  character,  and  cannot  be  distinguished 
from  monomania.  Any  one  of  the  four  terms  employed, 
monomania,  partial  insanity,  paranoia,  verrucktheit,  covers 
a  variety  of  cases  in  which  the  insane  range  is  limited,  and 
in  which  intellectual  competence  outside  it  still  holds  good. 
Where  there  is  emotional  and  moral  eccentricity,  as  in  some 
hereditary  cases  in  the  earlier  decades  of  life,  the  term  does 
not  fit,  and  in  the  latest  stage  of  true  monomania,  the  mental 
integrity  may  become  so  undermined  that  chronic  mania,  or 
dementia,  may  best  define  the  mental  state  of  the  patient. 

At  present  the  meaning  and  application  of  these  terms  is 
much  discussed,  and  the  particular  groups  of  symptoms 
which  should  properly  be  included  under  their  designation 
have  not  yet  been  determined  with  anything  like  unanimity. 
Chronic  progressive  delusional  insanity  has  been  expiscated 


i6o  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

from  the  general  pot-pourri,  and  for  the  present  we  may  con- 
tent ourselves  with  the  statement  that  (i)  there  is  a  distinct 
form  of  monomania,  characterized  by  suspicion,  hallucina- 
tions, and  delusions  of  persecution  and  unseen  agency  that 
may  be  secondary  to  acute  alcoholic  excitement,  or  a  gradual 
development  induced  by  chronic  alcoholism  ;  (2)  delusions 
of  unseen  agency  and  persecution  with  hallucinations,  com- 
bined with  partial  enfeeblement  in  hereditary  cases,  such 
patients  being  in  other  respects  amenable  and  fairly  sociable  ; 
(3)  a  form  of  monomania,  of  pride  and  grandeur  without 
previous  ideas  of  persecution,  the  S3^stematic  evolution  of 
vanity  and  egotism. 

^Etiology. 

Simple,  subacute,  acute  mania,  acute  delirious  mania — 
four  degrees  of  intensity — are  due  either  to  heredity,  a  pre- 
disposition caused  by  previous  attacks,  shock — surgical  or 
mental — phvsical  breakdown,  moral  causes,  alcoholic  excess, 
and  micntal  or  physical  exhaustion.  Two  or  more  of  these 
causes  may  operate  in  combination. 

Prognosis. 

In  this  disease  we  may  expect  one  or  other  of  the  following 
terminations  :  (i)  Recovery  by  lysis  or  crisis  in  about  50  per 
cent,  to  60  per  cent.  The  recovery  is  complete  and  satisfac- 
tory in  most  of  the  cases,  but  in  some  you  will  be  surprised 
to  find  a  certain  enfeeblement  remaining,  a  lack  of  that  com- 
plete consciousness  of  the  fact  that  there  has  been  anything 
wrong,  or  at  least  an  inability  to  recognise  the  full  significance 
of  some  things.  Thus,  a  young  girl  recovered  after  a  stormy 
attack  of  mania,  gained  flesh,  lost  entirely  her  muscular 
agitation,  occupied  herself  usefully,  but  remained  a  little  vain 
and  silly,  and,  on  hearing  that  her  father  and  mother  died 
during  her  illness,  was  in  no  wa}'  upset,  and,  when  taken  to 
see  their  graves,  recognised  the  fact  without  any  emotional 
equivalent,  speaking  of  it  in  a  most  matter-of-fact  way.  In 
this  case  there  was  a  return  to  the  status  quo  ante,  which  was 
that  of  a  mental  weakling.  Some,  however,  who  have  been 
previously  mentally  complete,  do  not  afterwards  regain  their 


MANIA  i6i 

full  status.  They  may  lack  their  old  courage,  or  find  their 
memory  fail,  or  in  some  other  way  exhibit  a  change. 
(2)  There  may  be  a  temporary  period  of  lucidity,  and  then 
a  recrudescence  of  the  attack  with  final  recovery.  (3)  The 
patient  may  pass  into  the  state  of  recurrent  or  chronic  mania. 
(4)  The  acute  symptoms  may  subside,  and  monomania  take 
possession  of  the  mind.  (5)  Dementia.  (6)  Death  from 
exhaustion  or  intercurrent  disease. 

In  coming  to  a  differential  prognosis  as  to  recovery, 
chronicity,  life  or  death,  we  have  as  a  basis  for  guidance  to 
consider  the  following  points  :  (i)  The  degree  of  oblivion, 
excitement,  sleeplessness  and  anorexia.  Can  we  prevent  the 
down-grade  of  physique,  can  we  check  the  failure  of  nutrition, 
and  restore  the  balance  of  waste  and  repair  ?  If  so,  death 
at  least  is  averted.  In  acute,  delirious  mania,  this  is  often 
impossible,  but  such  cases  do  sometimes  recover.  (2)  The 
absence  of  masturbation,  pyrexia  (above  100°),  signs  of 
organic  brain  disease,  and  fixed  delusions  are  good  signs. 
The  presence  of  fleeting  delusions  and  hallucinations  is  not 
of  grave  import.  The  case  may  end  in  general  paralysis,  and 
if  the  temperature  is  about  100°  or  more,  without  inter- 
current bodily  disease  to  account  for  it,  the  prognosis  should 
be  guarded.  (3)  A  short,  sharp  onset,  intensity  of  symptoms 
short  of  delirium,  a  good  appetite,  and  a  moderate  or  diminish- 
ing loss  of  weight,  are  favourable  signs. 

Treatment. 

Prophylactic. — If  we  can  detect  the  first  warnings,  and 
read  their  significance,  we  may  be  able  to  cut  short  an 
attack,  or  reduce  its  duration  and  severity.  It  is  well,  there- 
fore, to  note  the  following  prodromata :  Sleeplessness  and 
nocturnal  delirium,  change  of  mental  character,  irritability, 
restlessness,  morbid  suspicion,  a  fear  of  something  about  to 
happen,  headache.  We  find  sometimes  that  some  mental 
cause  may  have  been  operating  injuriously;  and  we  must 
inquire  if  there  is  a  history  of  insanity  in  the  family,  neurotic 
weakness,  epilepsy,  paralysis,  or  intemperance.  We  may 
remember  that  there  have  been  disturbing  moral  or  physical 
causes  ;  there  may  have  persisted  for  some  time  a  disturbance 

II 


i62  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

oF  bodil}'  function  or  some  grave  disease.  Possibly  consti- 
pation has  exercised  a  baneful  influence  unsuspected  for 
months.  The  patient  himself  ma}-  think  this  of  no  account. 
There  is  more  mental  disturbance  due  to  a  loaded  intestine 
than  many  suppose.  Therefore,  if  in  doubt,  give  a  sharp 
purge.  Mental  work  must  cease,  physical  exertion  and 
mental  diversion  are  imperative,  and  above  all  see  that  sleep 
is  obtained  by  a  hot  or  tepid  bath,  with  cold  to  the  head, 
friction  of  the  body  and  extremities  with  a  rough  towel, 
sulphonal,  or  some  other  sedative,  and  strict  attention  to  all 
the  rules  enjoined  for  procuring  sound  sleep.  In  this  way 
you  may  tide  over  or  mitigate  an  attack. 

The  treatment  of  fully-developed  acute  mania  is  a  more 
serious  matter.  If  the  friends  can  afford  it,  they  will  want 
him  treated  at  home,  or  at  any  rate  out  of  an  asylum.  The 
case  which  I  will  now  describe  to  you  is  an  example  of  one 
treated  out  of  an  as3'lum,  and  away  from  home ;  but  in  the 
great  majority,  unless  you  can  cut  short  an  attack,  the  most 
you  may  be  able  to  do  is  to  mitigate  its  severity  before  the 
patient  is  sent  to  the  asylum.  You  must  realize  that  any  case 
treated  in  private  practice  entails  on  the  physician  no  small  re- 
sponsibilit}' ;  but  if  he  averts  an  attack  of  insanity,  or  succeeds 
in  curing  it  at  home,  he  enjoys  a  measure  of  success  which  is 
very  gratifying,  and  the  patient  escapes  the  stigma  of  asylum 
lunacy.  From  what  I  have  said  already,  you  will  distinguish, 
so  far  as  mania  is  concerned,  what  cases  you  may  try  at 
home ;  but  you  must  have  skilled  attendants  who  under- 
stand clearly  the  risks  attending  the  case,  the  risk,  it  may  be, 
of  suicide,  homicide,  fire-raising,  or  destructive  violence. 
Whether  treatment  is  resorted  to  at  home  or  in  the  asylum, 
the  patient  must  have  almost  unlimited  muscular  exercise. 
Nature  herself  indicates  it ;  for  the  boiling  over  of  the  centri- 
fugal motor  energy  rushes  through  motor  channels,  and 
muscular  excitement  and  impulsiveness  is  the  result.  Give 
it  free  vent  therefore,  send  him  for  long  walks  with  his 
attendant,  or,  better  still,  give  him  active  exhausting  work. 
If  you  can  give  him  work  in  the  open  air  with  a  wheelbarrow, 
or  something  that  requires  more  brute  force  than  intelligent 
operation,  give  it  to  him  by  all  means.     If  possible,  let  him 


MANIA      ^  163 

have  a  tepid  bath  every  night  with  a  thorough  washing  down  ; 
let  him  be  well  rubbed,  and  at  bedtime  let  him  have  a  bowl  of 
gruel  or  porridge  and  milk  or  other  light  supper  before  being 
put  to  bed.  It  is  important  to  have  the  skin  kept  very  clean, 
and  the  pores  acting  well,  for  in  this  way  an  effective  drainage 
of  effete  matter  results,  and  in  addition  a  soothing  effect  is 
produced  on  the  nervous  system.  See  that  the  bowels  are 
moved  every  second  day  at  least ;  note  the  colour  of  the  stools, 
the  state  of  the  tongue,  and  other  indications,  so  as  to  obtain 
hints  for  treatment.  Remember  that  there  is  a  body  as  well 
as  a  mind  to  be  looked  after,  and  if  you  don't  look  after  the 
body  the  mind  will  not  be  restored.  That  is  so,  for  one  risk  in 
acute  mania  which  you  must  never  forget  is  the  risk  of  death 
from  exhaustion.  Take  the  case  in  time ;  feed  up  well  in 
the  early  days  of  the  attack ;  let  the  repair  at  least  be  com- 
mensurate with  the  waste.  As  regards  the  use  of  stimulants, 
be  cautious.  Where  you  have  extreme  dryness  of  lips  and 
tongue,  sordes,  a  sunken  expression,  a  very  rapid  pulse,  and 
intense  wakefulness,  stimulants  are  indicated ;  but  in  less 
critical  cases  it  may  be  found  that  they  induce  greater  excite- 
ment, and  you  must  withhold  or  diminish  the  dose.  These 
patients  are  not  sufficiently  conscious  as  a  rule  to  take  solid 
food  and  masticate  it  properly,  but  liquid  diet,  milk  and 
eggs,  beef-tea,  puddings,  and  gruel  or  porridge,  are  excellent 
kinds  of  food.  You  should  have  the  patient  frequently 
weighed,  at  least  twice  a  week,  and  as  long  as  he  is  losing 
weight  endeavour  by  every  means  in  your  power  to  keep  up 
the  supply  of  food,  even  to  repletion.  When  the  acute 
symptoms  pass  off,  the  pendulum  is  apt  to  swing  the  opposite 
way,  and  then  we  have  a  state  of  depression  ;  but  oftener 
a  condition  of  stupor,  which  frequently  passes  off,  and 
after  a  lapse  of  weeks  the  mind  brightens  and  recovery  is 
assured.  Whenever  there  is  depression,  guard  against 
suicide.  In  these  reactionary  states  tonics  are  indicated, 
and  you  must  be  careful  not  to  allow  stupor  or  depression 
to  take  too  deep  a  hold  of  the  mind,  but  rather,  by  patient 
and  steady  efforts  on  the  part  of  the  attendants,  to  lure  the 
patient  back  to  recovery.  In  some  cases  the  acute  mania 
passes  into  recurrent  mania  with  pauses  of  tranquillity,  de- 

II — 2 


i64  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

pression  or  stupor  between.  Do  not  despair  of  such  cases, 
feed  them  well,  get  up  their  body-weight,  increase  their  sleep 
by  work  or  exercise  in  the  open  air,  or  even  by  the  exhibition 
of  bromide  of  potassium  with  tincture  of  cannabis  indica. 
This  treatment  in  recurrent  cases,  especially  at  the  climac- 
teric, I  have  often  found  beneiicial.  I  am  strongly  averse 
to  narcotic  drugs  in  acute  cases,  and  regard  it  as  absolutely 
necessary  that  they  should  be  pushed  very  cautiously  as  long 
as  there  is  a  reasonable  hope  of  cure  by  other  means.  It 
is  believed  that  some  cases  have  been  made  chronic  and 
incurable  by  the  indiscriminate  use  of  narcotics  and  seda- 
tives, and  I  make  a  point  of  giving  nature  every  chance  for 
awhile,  and  only  employing  such  drugs  in  emergencies  and 
as  a  last  resort. 

Clinical  Illustrations. 

I.  Acute  Mania,  Heredity,  Loss  of  Child,  Religious  Excitement, 
Maniacal  Attack,  Constipation,  Quick  Recovery. 

John  M.,  hereditary  history,  married,  set,  34,  insane  three 
days,  but  attack  has  been  threatening  for  a  week.    Lost  a  little 
girl,  his  pet  child,  six  weeks  previously.     Being  very  sensitive, 
he  felt  this  most  keenly,  and  went  off  his  sleep.     By-and-by 
the  religious  consolations  common  at  such  times  began  to 
take  effect  on  him,  and  many  well-meaning  but  injudicious 
friends   overdosed  him  with   religious  literature  ;    his   mind 
endeavoured  to  tackle  abstruse  problems,  and  one  in   par- 
ticular, '  the  second  coming.'     The  first  thing  that  his  wife 
noticed    actually   wrong    was    his    getting    up    at    4  a.m., 
putting   on  his   clothes,    and  dressing  with   his   usual  care. 
She  called  out  to  him,   '  Where  are  you  going,  John  ?'  but 
he  seemed  unconscious,  as  if  in  a  dream,  and  left  the  room. 
She  hurriedly  got  up,  but  he  was  too  fast  for  her.     He  got 
out  of  the  house,  went  with  great  speed  to  a  house  on  the 
other  side  of  the  river,  singing  (or  rather  shouting)  hymns, 
and  fell  at  the  door  of  the  house.     The  man  of  the  house 
brought  him  back  home,  and  on  the  way  asked  him  what 
would  have  happened  if  the  bridge  across  the  river  had  been 
open.     '  Oh,'  he  replied,  '  I  felt  that  I  could  have  flown  over 
the  river.' 


MANIA  165 

I  arrived  on  the  Monday,  found  him  quiet  in  bed  after  a 
most  excited  morning ;  he  appeared  to  be  sleeping,  but  his 
sleep — if  sleep  it  was — was  restless,  his  head  moving  from 
side  to  side  on  the  pillow,  his  eyelids  bhnking ;  his  breath 
had  a  very  heavy  odour.  It  seemed  to  be  more  what  he 
himself  said  it  was,  '  a  trance  '  rather  than  a  sleep.  I  gave 
him  Potass.  Brom.,  Tr.  Cannabis  Indica.  After  coming  out 
of  one  of  these  trances,  he  in  three-quarters  of  an  hour  got 
into  what  might  be  called  a  waking  '  trance,'  stood  bolt 
upright  in  bed,  fixed  and  rigid.  By-and-by  I  got  him  to  lie 
down  and  try  and  sleep ;  but  he  was  now  in  a  half-conscious 
and  mischievous  mood,  would  pretend  he  was  asleep,  then 
in  a  moment  turn  round  and  prefer  a  request  for  the  '  po.' 
This  he  repeated  with  a  smile  frequently.  Two  hours  later 
he  got  a  few  hours'  sleep,  then  he  got  Ol.  Crotonis  in  Ol. 
Olivas,  which  worked  him  well,  and  for  a  few  hours  after  he 
was  much  more  sensible,  and  free  from  trances. 

At  bedtime  he  was  kept  in  a  sitz-bath,  with  cold  to  head, 
twenty  minutes,  then  had  gruel  and  sedative  repeated ;  he 
slept  one  and  a  half  hours  till  wakened  in  a  fright  with  the 
loud  rasping  of  a  door-lock.  For  several  hours  thereafter  he 
was  very  excited,  frightened,  and  argumentative  by  turns, 
talked  chiefly  on  religious  topics,  the  most  persistent  idea 
being  that  by  going  to  the  window  he  could  see  '  Shiloh 
come.'  To  some  persons  he  was  more  agreeable  than  to 
others ;  to  me  he  was  pleasant,  and  he  knew  me.  It  was 
plain  that  a  change  was  necessary  ;  lodgings  were  obtained 
for  him  near  Glasgow,  and  he  was  there  removed ;  had  to 
be  carried  downstairs,  but  walked  to  the  cab ;  called  his 
attendant  the  Christ  ;  though  restless,  remained  quiet. 

Notes  of  the  Case  in  Private  Lodgings. 

Height,  five  feet  nine  and  a  half  inches  ;  weight,  twelve 
stone  twelve  pounds  ;  pale  and  ashy-looking ;  bowels  con- 
fined ;  suffers  from  piles ;  tongue  dry  and  covered  with  a 
thick,  creamy  fur,  which  is  worse  in  the  morning.  Breath 
extremely  offensive.  Ordered  one  pill  Colocy.  c.  Hyoscy. 
daily ;  three  Permang.  of  Potash  pills  daily  (for  breath)  ; 
Liq.  Pepticus  (Benger)  with  food ;  and  a  time-table  and  diet- 


1 66  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

table  was  framed ;  to  have  at  least  seven  hours  in  the  open- 
air  daily,  and  a  sit2-bath,  with  cold  to  head,  for  two  nights 
running. 

The  first  night  he  had  no  sitz-bath ;  did  not  sleep,  very 
excited,  and  jumped  out  of  bed  at  usual  time  (3  a.m.),  and  was 
rather  unmanageable.  All  along  it  has  been  observed  that 
mental  lucidity  comes  every  now  and  again,  and  then  all  is 
darkness  ;  it  reminds  one  of  a  train  passing  through  many 
tunnels,  with  more  of  tunnel  than  of  daylight.  He  asks 
me  a  question  sensibly  and  coherently,  and  before  I  can 
reply  his  mind  is  encased  by  morbid  influence,  and  in 
another  world  as  it  were.  The  change  from  consciousness  to 
abstraction  is  so  sudden  as  to  be  really  striking.  The  second 
night  he  had  a  bath  and  slept  better ;  but  in  the  morning, 
though  freer  from  trances  and  fits  of  abstraction,  he  was  very 
argumentative,  and  tried  to  take  to  pieces  all  I  said  and  trip 
me  up.  His  intellect  was  not  acute  and  clear  as  of  old, 
and  such  mental  exertion  clearly  exhausted  him.  He  would 
begin  a  question,  and  suddenly  stop,  saying,  '  I  forgot  what  I 
was  going  to  ask  you  about.'  Ordered  two  Colocynth  pills  next 
day  (walked  eighteen  miles) ;  must  be  very  tired,  but  there  is 
no  sense  of  fatigue.  Was  evidently  battling  within  himself  the 
sound  with  the  unsound  mind;  kept  continually  asking  in 
the  bath,  '  Is  this  a  delusion  ?'  'Is  Mary  dead  and  in 
churchyard?'  or  'Am  I  dead  and  she  living?'  Had  a  bad 
night,  but  bath  and  friction  evidently  helped  the  action  of 
pills,  and  with  great  ease  he  got  a  copious  movement  of 
bowels,  filling  in  twenty-four  hours  nearly  two  pots.  The 
moving  of  the  bowels  had  had  a  most  marked  relation  to 
an  improvement  in  his  mental  condition. 

//.  Acute  Mania,  Second  Attack,  Heredity,  Poisoned  Finger, 
Dry  Pack  for  Surgical  Reasons,  Long  Period  of  Acute 
Excitement  with  Remissions,  Great  Loss  of  Weight  and 
Sleeplessness. 

Mrs.  M.  L.,  get.  47.  Medical  certificates  were  as  follows  : 
'  She  has  a  wild  expression  of  countenance,  and  talks  con- 
tinually.  Her  language  is  foul,  and  she  is  very  outrageous.   She 


MANIA  :i67 

says  that  she  has  been  begging  for  two  weeks,  and  that  her 
money  has  been  stolen — both  delusions.  She  talks  about  kill- 
ing cattle  in  the  bed,  and  other  things  that  are  not  true,'  etc. 

History. — Her  father  was  confined  in  an  asylum  at  five 
different  times.  He  drank  heavily,  and  was  subject  to  fits. 
A  niece  of  his  is  confined  in  an  asylum,  and  a  brother  of 
patient's  was  insane.  She  was  insane  and  confined  at  age 
of  eighteen.  Has  always  been  an  excitable,  hard-working 
woman.  A  week  before  this  attack  she  cut  her  hand  acci- 
dently,  dirt  got  into  it,  and  she  suffered  with  it  very  much, 
and  lost  her  sleep.     She  was  a  very  temperate  woman. 

State  on  Admission. — Pulse  130,  small  but  wiry.  Heart's 
sounds  normal.     Respiratory  system  normal. 

Nervous  System.  —  Knee-jerks  exaggerated;  sensibility 
quickened  ;  pupils  dilated,  and  react  slowly  to  light  ;  right 
hand  greatly  swollen  and  inflamed  as  the  result  of  cellulitis, 
and  has  been  incised  at  three  places. 

Cotirse  of  Case. — Extreme  excitement,  violence,  and  abusive 
and  indecent  language  of  the  worst  description.  Only  ceases 
for  a  moment  when  she  is  out  of  breath.  Sleepless  and 
refuses  food,  requiring  to  be  fed  by  the  stomach-tube. 
Hyoscine  injections  for  the  sake  of  the  hand. 

Later. — Put  in  dry  pack,  as  hand  is  looking  bad,  and 
amputation  is  in  prospect  if  surgical  rest  is  not  obtained. 
Still  fed  by  stomach-tube  ;  steadily  losing  weight. 

Later. — Hand  improving,  but  excitement  still  severe  ;  she 
is  taking  her  food,  but  is  very  sleepless.  Her  language  is 
as  offensive  as  ever ;  but  she  seems  more  conscious  than  she 
was  at  first,  for  in  the  few  lucid  intervals  she  had  in  the  first 
month  of  her  illness  she  was  surprised  to  know  how  bad  she 
was.  Unfortunately,  these  lucid  intervals  were  only  of  a  few 
hours'  duration.  She  is  now  ordered  sulphonal  night  and 
morning,  for  she  has  lost  much  in  flesh  and  strength,  and 
her  continuous  wakefulness  is  very  exhausting. 

Prese7it  Time. — She  has  gained  weight,  and  though  still 
excited,  the  mental  disturbance  is  less  acute,  less  blasphe- 
mous, more  playful  and  she  is  mischievous,  and  more  coherent. 
The  hand  has  healed,  and  amputation  has  been  averted. 


i68  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

ACUTE    DELIRIOUS    MANIA. 

///.  Sequel  to  Second  Attack  of  Influenza,  Rapid  Coiirse,  Death. 

Mrs.  F.  C,  set.  39,  had  two  attacks  of  influenza,  and 
became  acutely  excited,  '  singing,  laughing,  crying,  tearing 
the  paper  off  the  walls,  striking  at  those  in  attendance, 
passing  her  water  in  bed,  trying  to  burn  the  bedclothes,  and 
wanting  to  throw  her  youngest  child  into  the  fire.  Threw 
money  into  the  fire,  and  tore  her  clothing.' 

Such  was  her  state  before  admission,  and  it  corresponds 
with  our  description  of  acute  mania  of  an  intense  character ; 
but  compare  it  with  her  condition  in  the  asylum  a  few  days 
later,  and  we  find  a  more  marked  oblivion  and  a  more 
delirious  state. 

First  Note. — '  On  admission  she  was  in  a  state  of  extreme 
maniacal  excitement,  but  it  was  wild,  irrelevant,  crazy, 
delirious  ;  continuous  motor  restlessness ;  all  the  limbs  in 
a  state  of  agitation.  She  kept  muttering  to  herself  indis- 
tinctly, and  her  attention  could  not  be  fixed.  She  was  in 
a  strange  environment  of  her  own.  Slept  little  or  none. 
Tongue  very  dry ;  sordes  round  the  teeth,  on  lips  and 
tongue ;  hollow,  sunken  eyes ;  dry,  parched,  earthy  com- 
plexion. Pulse  78,  small  and  compressible.  Pupils  medium, 
reaction  sluggish;  knee-jerks  normal.  Required  to  be  fed 
by  stomach-tube.' 

Second  Note  {a  fortnight  later). — '  Has  had  sleep  on  several 
nights,  but  now  it  has  entirely  left  her,  and  she  requires 
hyoscine.  Her  temperature  chart  is  very  erratic^  ranging 
from  97"2°  (morning)  to  101*2°  (evening)  ;  still  fed  by  stomach- 
tube.  She  seems  to  have  hallucinations  of  sight,  for  she 
stares  anxiously,  seems  in  mortal  fear,  and  puts  out  her 
hands  as  if  to  avert  some  fearful  catastrophe.  Is  fed  thrice 
daily  ;  gets  6  ounces  whisky  daily.  Albumin  in  slight  amount 
in  urine.' 

Third  Note  {five  weeks  later).  —  'Much  weaker;  pupils 
dilated ;  reflexes  gone ;  lips  raw  and  bleeding ;  offensive 
breath ;    desquamation.      Diarrhoea   obstinate  and   profuse. 


Plate  HI.— MANIA  AND  FOLIE  CIRCULAIRE. 


> 

ACUTE    MANIA. 


ACUTE   MANIA 
(ATTENTION    ARRESTED). 


CHRONIC    (destructive)    MANIA. 


FOLIE   CIRCULAIRE 
(MELANCHOLIC    STAGE). 


FOLIE    ClKCCLAIkE 
(MANIACAL    STAOE). 


To  face />   1 68. 


MANIA  169 

Sleep  impossible  even  with  large  doses  of  hyoscine.  Seems 
in  a  state  of  coma  vigil.  Restlessness  has  ceased.  Pulse 
scarcely  perceptible,  ranges  from  60  to  120.' 

Fourth  Note  {a  week  later). — '  Died  this  morning.  Her 
temperature  had  risen  during  the  last  few  days  to  102°  and 
103°.     Bed-sores  broke  out  at  last.' 

Post-mortem  examination  revealed  an  exceedingly  serous 
state  of  the  blood,  the  faintest  possible  attachment  of  the 
dura  mater  to  the  cranium,  and  of  the  pia  mater  to  the 
brain  ;  no  enteritis,  but  a  much-distended  caecum.  Enlarged, 
congested,  and  softened  liver  and  spleen ;  enlarged  kidneys 
from  congestion,  their  capsules  stripping  off  easily. 

CHRONIC    MANIA. 

IV.  Loss  of  Money,  Acute  Mania,  now  Chronic  after  Three  and 

a  Half  Years. 

Mrs.  B.  G.,  set.  49.  After  a  long  attack  of  acute  mania, 
she  toned  down  considerably,  but  is  still  rather  noisy  and 
exalted.  She  has  hallucinations  of  hearing,  talks  to  imaginary 
persons,  and  either  receives  from  them  sexual  suggestions 
or  these  arise  as  delusions.  She  replies  in  most  abusive 
language ;  but  she  has  an  amount  of  insane  self-satisfaction 
that  keeps  her  merry  and  noisy  all  the  time.  She  decks 
herself  with  cheap  finery,  and  is  rather  vain  of  her  appearance. 
She  is  very  incoherent  and  irrational  in  general  conversation, 
and  has  numerous  delusions  regarding  marriage,  the  posses- 
sion of  money,  etc.  This  patient's  mental  condition  does 
not  prevent  her  eating,  sleeping,  and  working  well.  She  is 
a  first-class  laundress. 

RECURRENT    MANIA. 

V.  A    Schoolmaster :    Recurrent   Excitement,  Exaltation,  some- 

times Violent. 

A.  G.,  set.  ^y,  insane  two  years.  On  admission  he  was 
quiet,  docile,  intelligent,  and  to  all  intents  and  purposes 
well,  and  remained  so  for  some  weeks,  making  himself  useful 
and  in  all  respects  amenable  to  the  rules  of  the  house.  Since 
then  he  has  had  attacks  of  excitement  recurring  every  two 


I70  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

months.  He  is  ill  about  two-thirds  of  the  time,  and  well 
one-third.  His  attacks  are  getting  worse.  They  come  on 
with  very  slight  warning.  He  becomes  loquacious  without 
rhyme  or  reason,  talks  incessantly  and  incoherently  on  botany, 
chemistry,  astronomy,  mathematics,  '  matters  animal,  vege- 
table, mineral.'  His  schoolmaster's  brain  is  jumbled  up,  and 
when  the  tap  of  incoherence  is  turned  on  he  shouts  for  days, 
and  only  ceases  when  sleep  overtakes  him.  At  present  he  is 
in  one  of  these  attacks,  and  is  more  aggressive  and  dangerous 
than  formerly.  He  begins  in  the  morning — crescendo ;  he 
is  at  his  worst  in  the  afternoon,  and  subsides  rather  in  the 
evening.  His  condition  is  one  of  exaltation  with  excitement 
and  incoherence. 

VI.  A  Soldier :  Bidlet-wouiid,  Bullet  not  extracted,  Several 
A  ttacks  of  Insanity  since,  now  Recurrent  Mania  of  Religious 
Form. 

J.  M.,  aet.  40,  was  wounded  in  Egypt  in  1881,  since  which 
he  has  had  several  attacks  of  acute  insanity,  always  taking  a 
religious  form.  He  has  often  been  discharged  recovered; 
but  the  attacks  come  so  close  together  in  point  of  time  that 
he  cannot  be  discharged  again,  his  insanity  being  now  a 
recurrent  mania.  On  the  verge  of  an  attack  he  becomes 
extremely  nervous,  every  muscle  of  his  face  quivering.  Soon 
he  gets  irritable  and  argumentative,  wants  to  engage  in 
religious  devotions  all  the  time,  then  becomes  noisy  and 
declamatory,  and  wild  and  excited  in  appearance ;  has  hallu- 
cinations of  hearing,  and  says  that  God  is  speaking  to  him. 
His  excitement  goes  on  increasing  until  restraint  is  absolutely 
necessary,  for  he  becomes  violent  and  dangerous. 

He  is  a  very  devout  Catholic,  and  between  attacks  is 
allowed  to  go  to  chapel  on  Sundays  by  himself  One 
Sunday  lately  he  went  off  apparently  all  right,  but  did  not 
turn  up  at  night.  He  got  excited,  bat  not  dangerous ; 
travelled  from  place  to  place  about  forty  miles  in  twenty- 
four  hours,  and  at  last  was  brought  back  by  the  police. 
This  free,  unrestrained  exercise  seems  to  have  worked  off 
the  excitement,  and  this  has  been  his  shortest  attack  on 
record. 


FOLIE  CIRCULAIRE— ALTERNATING  INSANITY         171 


FOLIE    CIRCULAIRE. 

VII.  Mania  followed  by  a  Period  of  Mental  Enfeeblement,  de- 

veloping ultimately  into  Folie  Circulaire. 

A.  L.,  aet.  51,  insane  for  about  twenty  years.  He  has  for 
the  last  ten  years  passed  through  cycle  after  cycle  of  folie 
circulaire.  When  he  is  depressed  he  says  he  is  dying ;  when 
he  is  excited  he  says  he  is  the  strongest  man  in  the  world. 
There  is  a  want  of  mental  grip  in  his  case  :  he  is  rather 
childish  and  cowardly  when  excited.  The  cycle  begins  thus  : 
For  about  ten  days  he  refuses  to  get  up  in  the  morning, 
complains  of  pain  in  back  and  sides,  refuses  breakfast,  but  is 
all  right  in  the  afternoon.  At  the  end  of  that  time  he  gets 
up  in  the  morning  before  the  other  patients,  begins  to  boss 
them,  and  tries  to  get  them  out  of  bed.  He  develops  at 
once  his  delusion  that  he  is  a  second  Goliath.  In  this  stage 
he  masturbates,  is  noisy,  offensive  in  his  language,  and  ready 
to  fight  anyone.  This  lasts  twenty-four  to  twenty-eight 
days.  Then  he  becomes  dull,  stupid,  lazy,  and  will  sleep  all 
day  if  allowed.  The  stuporose  state  continues  about  five 
weeks.  As  the  disease  progresses  we  observe  that  the 
stuporose  stage  lengthens,  and  the  excited  periods  shorten. 
The  melancholic  stage  lasts  three  to  four  weeks,  but  is  not 
active  except  for  ten  days  before  the  maniacal  attack. 

ALTERNATING    INSANITY. 

VIII.  Melancholia    at    Climacteric    followed    by    Mania   with 

Exaltation. 

Mrs.  C.  M.,  set.  48,  widowed.  Very  much  emaciated  ; 
won't  enter  into  conversation ;  refuses  to  take  food  or 
medicine  for  fear  of  being  poisoned ;  prefers  to  die.  Has 
threatened  on  several  occasions  to  commit  suicide.  Is  afraid 
that  she  may  be  impelled  to  injure  some  of  her  family. 
Cannot  sleep  at  night.  Walks  the  floor  all  night,  her  melan- 
choly is  so  unbearable.  Exophthalmic  goitre  of  small  size. 
Her  attack  began  with  religious  scruples  and  misgivings,  and 
she  neglected  her  health.     She  recovered  in  six  months. 


172  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

She  was  well  for  four  months,  then  she  became  rather 
elevated,  gradually  developing  into  a  state  of  exaltation  with 
delusions  of  grandeur.  She  became  restless,  would  not 
stay  at  home,  went  to  sales  and  bought  what  she  had  no 
need  and  could  not  pay  for.  Thereafter  her  talk  was  of 
marriage.  She  entertained  the  idea  that  she  was  Lady  M., 
and  was  about  to  marry  a  millionaire.  She  lost  flesh  to 
an  alarming  extent  while  her  excitement  lasted.  Under 
generous  diet  and  tonic  treatment  she  gained  weight,  and 
recovered  in  six  months.  She  is  now — three  months  later 
— unnaturally  quiet,  and  looks  like  one  passing  into  a  state 
of  depression. 

IX.  Monomania  of  Pride. 

M,  M.,  set.  27,  was  a  dressmaker.  She  is  a  very  intelli- 
gent girl ;  but  she  has  developed  by  slow  but  sure  degrees 
from  the  simple  vanity  of  youth,  continually  stimulated  by 
draping  her  handsome  figure  in  a  first-class  dressmaking 
saloon,  until  now  she  has  one  alL-absorbing  idea — her  ex- 
ceptional figure  and  her  good  looks.  She  will  spend  all 
day  looking  in  the  glass,  dressing  and  redressing  herself, 
posing  in  various  attitudes  and  admiring  herself.  Behind  all 
this,  however,  there  is  a  feeling  of  regret  and  sadness  that 
she  should  have  allowed  pride  of  appearance  to  take  posses- 
sion of  her  to  such  an  extent  that  she  has  become  a  useless 
member  of  society.  Here  is  a  strange  morbid  inconsistency 
of  character. 


CHAPTER  X. 

ANERGIC  STUPOR,  DEMENTIA,  INSANITY  OF  MASTURBA- 
TION, MORAL  INSANITY,  IMPULSIVE  INSANITY. 

A  distinction  drawn  between  stupor  and  dementia,  illustrated  by  a 
description  of  the  experiments  of  Binz  on  fresh  nerve-cells — Reaction 
time — Anergic  stupor — Dementia — Masturbation  as  a  cause  of  in- 
sanity, and  as  a  symptom — Several  stages  and  diversities  of  insane 
character — Physical  changes — Moral  insanity — Opposing  views  on 
this  question  —  Impulsive  insanity  —  Self-mutilation  —  Suicide- 
Homicide — Sexual  perversion  or  excess — Destructiveness — Klepto- 
mania— Pyromania — Dipsomania  —Clinical  illustrations. 

In  the  previous  chapter  dementia  was  given  as  a  sequel  of 
mania,  and  in  Chapter  VIII.  the  melanchohc  form  of  stupor 
was  described.  It  is  now  necessary  to  distinguish  between 
stupor  and  dementia,  because  writers  and  teachers  use  these 
terms  differently.  According  to  some,  melancholic  stupor  is 
the  only  stupor  in  the  insane  state ;  and  what  is  called 
anergic  stupor  by  Newington  and  Clouston  has  been  re- 
garded by  others  as  acute  or  primar}^  dementia.  These 
terms  are  therefore  convertible,  but  not  so  the  generic  term 
dementia  ;  and  as  confusion  is  likely  to  arise,  for  true  dementia 
is  something  graver  than  stupor,  the  use  of  the  designation 
acute  oi  primary  dementia  should  be  withdrawn. 

In  order  to  understand  the  distinction  between  stupor  and 
dementia,  we  may  take  for  illustration  the  experiments  of 
Binz  with  morphine  on  nerve  cells  (Lectures  on  Pharma- 
cology, New  Sydenham  Society).  He  found  that  when 
morphine,  a  neutral  solution  of  chloral  hydrate,  or  the 
vapour  of  chloroform  was  applied  to  fresh  brain,  opalescence 
or  clouding  of  the  brain  cells  took  place.     The  whole  process 


174  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

appeared  to  resemble  a  coagulative  necrosis,  for  in  similar 
experiments  on  the  protoplasm  of  infusoria,  which  were 
treated  with  toxines,  it  was  observed  that  the  protoplasm 
soon  became  clouded,  and  the  movements  sluggish,  while  if  the 
toxic  action  was  continued,  the  protoplasm  became  granular, 
and  the  movements  ceased.  Recovery  may  occur  in  the 
iirst  stage  if  the  poison  is  quickly  washed  out,  but  not  from 
the  latter  stage.  The  one  may  be  compared  to  the  stupor 
or  sleep,  the  other  to  the  death,  of  the  cell.  These  distinc- 
tions are  well  seen  in  the  mental  down-grade  of  the  mastur- 
bator.  He  has  many  recoveries  from  stupor,  but  they  are 
less  and  less  complete  as  time  goes  on ;  necrosis  is  making 
headway,  and  dementia  is  the  final  negative  result. 

In  the  sleep  stage,  therefore,  we  have  the  condition 
analogous  to  stupor.  In  the  death  of  the  cell  we  have  the 
condition  analogous  to  dementia.  Stupor,  therefore,  may 
pass  into  dementia ;  but  as  long  as  the  condition  is  one  of 
stupor  we  may  hope.  For  this  reason  anergic  stupor  is  a 
better  term  than  acute  primary  dementia,  because  recovery 
may  still  take  place  ;  and  the  term  '  dementia  '  will  be  reserved 
for  actual  death  of  mind  in  greater  or  less  degree,  for  some 
flickering  of  mental  activity  is  always  possible  till  the  last 
stage  of  all,  when  death  is  on  the  threshold. 

It  is  very  important  now  for  us,  before  going  further,  and 
preparatory  to  doing  so,  to  discriminate  between  melancholic 
stupor  and  anergic  stupor.  I  must  draw  your  attention  to  a 
very  important  means  of  gauging  in  some  measure  the 
mental  activity  of  the  insane,  which,  though  specially 
applicable  here,  is  useful  in  all  clinical  studies  of  mental 
disease.  This  mental  gauge  refers  to  the  speed  of  mental 
processes,  and  is  called  '  the  law  of  mental  reaction.'  A 
summary,  but  quite  a  sufficient  one  for  our  purpose,  may  be 
quoted  from  Ladd's  '  Physiological  Ps3-chology '  (pp.  470, 
471).  '  Exner  finds  seven  elements  in  all  reaction-time; 
(i)  An  action  of  the  stimulus  on  the  end-organ  of  sense 
preparatory  to  excitation  of  the  sensor}-  nerve  ;  (2)  centri- 
petal conduction  in  this  nerve ;  (3)  centripetal  conduction  in 
the  spinal  cord  or  lower  parts  of  the  brain  ;  (4)  transforma^ 
tion  of  the  sensory  into  the  motor  impulse ;  (5)  centrifugal  con- 
duction of  the  impulse  in  the  spinal  cord;   (6)  centrifugal 


ANERGIC  STUPOR  175 


conduction  in  the  motor  nerve ;  (7)  setting  free  of  the 
muscular  motion.  Of  these  seven  factors,  however,  the 
fourth  is  most  interesting  to  psychology.  It  may  properly 
be  called  psycho-physical,  as  distinguished  from  more  purely 
physiological  time.  The  other  six  elements  (with  the  excep- 
tion of  the  first,  on  account  of  difficulties  inherent  in  the 
experiments),  have  been  determined  with  some  degree  of  de- 
finiteness  (see  Part  I.,  Chapter  III.,  on  the  Speed  of  Nervous 
Processes).  It  is,  then,  theoretically  possible  to  ascertain  the 
amount  of  these  six  and  subtract  them  from  the  entire 
reaction-time ;  the  remainder  would  be  the  interval  occupied 
by  the  central  cerebral  processes  (that  is,  by  No.  4).  Thus, 
Exner  assumes  sixty-two  metres  per  second  as  the  probable 
rate  of  conduction  in  both  sensory  and  motor  nerves  ;  and 
in  the  spinal  cord,  eight  for  the  sensory  and  eleven  to  twelve 
for  the  motor  process.  He  thus  calculates  that  about  0*0828 
seconds  is  the  "reduced  reaction-time,"  or  interval  occupied 
within  the  cerebral  centres  in  transforming  the  sensory  into 
motor  impulses,  in  the  special  case  of  reaction  from  hand  to 
hand,  where  the  whole  reaction-time  is  0"i337  seconds. 
The  uncertainties  of  all  such  calculation,  however,  occasion 
the  demand  for  other  methods  of  determining  the  strictly 
"  psycho-physical  "  portion  of  reaction-time.' 

Difficulties  will  always  be  met  with  in  testing  the  reaction- 
time  of  the  insane,  even  with  the  best  instruments  that  can 
be  devised  for  the  purpose.  In  actual  practice  distinctions 
sufficiently  approximate  can  usually  be  drawn ;  but  as 
science  demands  measurements,  and  they  indicate  more 
trifling  variations  than  can  be  appreciated  by  the  unaided 
senses,  it  is  probable  that  a  routine  of  measurements  will  yet 
come  into  vogue  in  asylum  practice.  In  all  cases,  however, 
there  is  the  difficulty  of  truthfully  estimating  the  time 
absorbed  by  six  of  the  seven  elements,  which,  though  ac- 
curately ascertained  in  the  case  of  animals  by  experiment, 
must  always  be  a  matter  of  doubt  because  of  differences  in 
the  personal  equation  of  each  individual  studied.  For  the 
present  we  must  reckon  the  total  of  the  seven  elements,  and 
compare  sane  with  insane  in  a  large  number  of  individuals, 
and  with  careful  elimination  of  emotional  elements  and  dis- 
tracting stimuli. 


176  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

Despite  the  inherent  difficulties  of  the  subject,  I  need 
scarcely  say  that  the  reaction-time  is  a  clinical  factor  of 
importance.  Every  man  and  woman  has  a  reaction-tim-e 
which  varies,  slow  to  respond  at  one  time  and  quick  to 
respond  at  another ;  but  in  mental  disease  the  variations 
are  much  more  pronounced ;  and  in  stupor  the  term  '  re- 
action-time '  may  be  practically  a  dead  letter,  for  response  is 
usually  nil,  or  next  to  nil.  The  quicker  the  time-reaction, 
the  less  the  stupor ;  the  slower  the  time-reaction,  the  deeper 
the  stupor. 

The  impression  seems  to  prevail  that  anergic  stupor 
implies  a  more  complete  loss  of  consciousness  than  obtains 
in  melancholic  stupor,  the  mind  being  often  for  a  time  at 
least  null  and  void ;  and  if  recovery  takes  place,  there  is  no 
recollection  of  events  synchronous  with  the  stupor,  nor  any 
evidence  that  there  ever  was  any  perception.  The  patient 
figuratively  is  a  mere  organic  automaton;  there  is  complete 
immobility,  and  no  resistance  is  made  to  passive  movements. 
The  circulation,  as  in  melancholic  stupor,  is  very  weak ; 
oedema  and  cyanosis  of  hands,  feet,  and  other  terminal 
parts  results  from  feeble  cardiac  action  and  the  absence 
of  muscular  activity. 

The  onset  of  anergic  stupor  is  usually  sudden,  not 
gradual,  as  stated  by  Savage  in  his  scheme  of  comparison 
between  melancholic  stupor  and  primary  dementia  (anergic 
stupor).  This  statement,  that  the  onset  of  anergic  stupor  is 
gradual,  is  contradicted  by  a  case  which  he  reports  a  few 
pages  further  on  ('  Insanity  and  Allied  Neuroses,'  p.  210). 
It  was  the  case  of  a  young  farmer,  with  inherited  mental 
taint,  who  was  frightened  by  some  fireworks  thrown  at  him 
as  he  went  along  a  dark  lane.  He  got  home,  but  remembered 
nothing  about  the  journey,  nor  his  actions  after  he  was 
there.  When  taken  out  of  bed  he  stayed  where  he  was 
placed.  At  intervals  he  was  violent,  and  seemed  to  see 
some  dreadful  object.  His  mind  was  a  total  blank  from 
November  till  June  i.  He  was  roused  by  galvanism,  and 
recovered.  The  hallucinations  of  sight  prove  that  conscious- 
ness was  not  absolutely  abolished,  but  memory  probably 
was.     According  to  Newington,  the  onset  is  usually  rapid. 


ANERGIC  STUPOR  177 


In  reviewing  my  experience  of  stuporose  patients  in  order 
to  find  a  definite  case,  on  looking  up  old  case-books,  and 
carefully  scrutinizing  the  clinical  material  at  present  under 
treatment,  I  find  it  very  difficult  to  decide  on  cases  of 
anergic  stupor  ;  but  one  case  looms  out  clearly  from  the 
others,  though  on  searching  the  records  I  find  that  there 
was  not  absolute  unconsciousness,  and  as  she  has  not  re- 
covered we  are  unable  to  say  much  of  her  memory.  She 
certainly  learned  to  find  her  way  about  in  the  wards,  but  an 
idiot  of  the  average  type  would  certainly  learn  more.  It  is 
interesting,  however,  to  observe  that,  like  the  case  described 
by  Savage,  and  which  I  have  just  quoted,  she  was  afraid, 
and  saw  dreadful  objects — rats  in  her  room,  a  dog  in  the 
bed,  etc.  The  fact  that  there  may  be  delusions  or  hallucina- 
tions in  these  cases,  or  an  unaccountable  dread,  would, 
according  to  Newington,  place  them  in  the  category  of 
melancholia  with  stupor  ;  and  I  confess  to  a  strong  con- 
viction, the  more  I  have  studied  these  cases,  that  true 
anergic  stupor  of  sudden  onset,  without  mental  activity  of 
any  kind,  entire  suspension  of  memory,  a  complete  negative 
existence,  is  exceedingly  rare. 

The  best  examples  I  have  seen  of  anergic  stupor  are  those 
following  fevers,  and  in  these  cases  mental  and  physical 
negation  is  most  marked.  In  maniacal  cases,  especially  in 
women,  a  state  of  mental  torpor  supervenes  when  the  acute 
symptoms  subside.  This  state  is  often  temporal  and  dis- 
appears, the  patient  waking  up  to  normal  consciousness  ; 
but  it  may  deepen  and  pass  into  dementia. 

Two  ways  of  waking  up  may  be  noticed  in  all  forms  of 
stupor,  (i)  The  usual  way  is  by  slow  degrees,  a  gradual  re- 
cuperation of  all  the  powers,  physical  and  mental ;  but  the 
recuperation  may  reach  a  stage  where  it  stops  short,  and 
reveals  to  us  the  disappointing  fact  that,  though  the  patient 
now  walks,  eats,  dresses  herself,  and  engages  in  occupation, 
delusions,  insane  conduct,  or  absurd  conceits  still  obtain. 
It  may  be  otherwise — full  recovery  may  take  place.  (2)  A 
second  way  in  which  the  darkness  of  mind  is  dispelled  is  by 
more  rapid  recovery — a  sudden  recovery  may  take  place 
which  may  be  complete,  or  only  apparent  at  first,  until  the 

12 


178  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

actively -ins&ne  mind  reappears.  Many  cases  of  stupor  are 
very  disappointing.  Even  with  recovery  from  stupor,  there 
is  still  something  wanting  in  many  cases. 

Stupor  of  anergic  form  in  its  most  profound  state  is  seen 
in  the  epileptic  after-seizures,  and  it  may  last  for  hours, 
sometimes  longer.  It  is  seen  also  incidentally  in  the  course 
of  general  paralysis,  after  excessive  masturbation,  following 
attacks  of  excitement,  especially  during  puberty  or  adoles- 
cence, and,  as  already  mentioned,  usually  prior  to  recovery 
from  maniacal  attacks. 

The  treatment  of  all  forms  of  stupor  is  the  same  in 
principle,  viz.,  to  treat  S3^mptoms.  For  cold  hands  and 
feet  promote  warmth,  and  as  there  is  so  little  energy  manifest, 
give  passive  exercise  and  conserve  the  strength  and  physical 
condition  as  much  as  possible.  Individualize  the  patient ; 
reach,  if  possible,  his  dormant  consciousness,  and  rouse  it. 
These  cases  often  require  very  great  patience  and  persever- 
ance. Galvanism  sometimes  does  good ;  friction,  forced 
exercise,  everything  that  will  rouse  him,  helps  to  keep  the 
sleeping  cells  from  passing  into  the  death  state  of  dementia. 
Feeding  and  attention  to  the  bowels  are  very  important 
necessities. 

Dementia. 

Dementia  means  mental  wreckage,  the  result  of  storms  of 
mental  excitement  or  the  ravages  of  organic  disease.  It  is 
a  law  of  Nature  that  prolonged  exercise  induces  fatigue,  and 
prolonged  excitement  induces  exhaustion.  Mental  exhaus- 
tion is  evinced  b}'  more  or  less  stupor,  but  prolonged  con- 
tinuance of  mental  excitement  may  exhaust  and  disintegrate 
the  mental  faculties  beyond  hope  of  restoration.  Dementia 
is  never  absolute  and  complete  ;  the  mind  is  still  afloat,  its 
light  feebl}'  burning,  but  the  degree  of  wreckage  in  a  hundred 
dements  varies  as  much  in  quantity  as  we  can  possibly  con- 
ceive. It  is  often  very  difficult  to  estimate,  for  who  can  tell 
how  much  of  consciousness  and  mental  activity  remains  in 
these  silent,  inert  human  beings  who  automatically  rise  and 
dress  in  the  morning,  go  to  meals  and  eat  to  repletion,  go 
out  to  work,  or  walking  exercise,  and  so  on,  silently,  without 


DEMENTIA  179 


comment,  or  evident  interest  in  events,  living  their  negative 
lives  from  day  to  day  ? 

Sometimes  we  are  astonished  when  a  man  who  has  been 
practically  a  cipher  for  a  year  or  more  prefers  a  request  or 
mterjects  a  remark,  and  we  wonder  if  he  has  been  a  silent 
philosopher  all  the  time  ;  but  in  such  cases  it  is  often  a 
feeble  flicker  of  mental  life  just  for  a  moment,  a  flicker 
which  dies  out  as  suddenly  as  it  appeared. 

Nevertheless,  we  can  discern  degrees  of  dementia,  and  the 
extreme  cases  are  more  likely  to  be  such  as,  having  inherited 
unstable,  imperfectly-developed  brains,  have  broken  down 
under  the  strain  of  excitement,  having  no  mental  residuum 
to  fall  back  on.  Dementia  which  follows  the  excitement  of 
middle  life  is  less  common,  and,  as  a  rule,  it  is  less  extreme. 
In  the  industrial  community  of  an  asylum,  there  are  always 
dements  of  this  class,  who  have  not  lost  all  their  acquisi- 
tions, whose  memories  are  not  denuded  of  all  that  they  had 
previously  learned,  and  who,  while  no  longer  receptive  of 
new  impressions,  no  longer  interested  in  events,  are  yet  able 
to  labour  with  their  hands,  and  automatically  to  employ 
themselves  in  various  kinds  of  labour. 

Dementia  may  show  itself  in  loss  of  memory,  inability  to 
comprehend  or  answer  any  but  simple  questions,  loss  of 
power  to  think  out  questions,  loss  of  attention  to  all  but 
mechanical  duties,  loss  of  affection,  diminution  of  will-power, 
reduction  of  the  moral  sense.  It  is  noticeable,  however,  that 
old  acquisitions  and  habits  are  retained  more  persistently 
than  recent  ones ;  and  a  man's  memory  may  be  good 
enough  for  routine  office  work,  though  he  takes  no  note 
of  his  surroundings,  knows  not  the  day  of  the  week  or 
what  he  had  for  breakfast.  We  find  many  such  patients, 
who  do  not  know  the  names  of  their  doctors  or  attendants, 
or  the  names  of  the  other  patients,  and  some  are  still  com- 
petent in  their  calling,  as  joiners,  masons,  labourers,  clerks, 
etc. 

Dementia  may  be  regarded  as  of  two  kinds :  (a)  Con- 
secutive— consequent  on  prolonged  excitement  or  epileptic 
disturbance;  (b)  organic — the  result  of  gross  brain  lesion. 
In  the  latter  the  degree  is  usually  more  marked,  and,  as  a 

12 — 2 


i8o  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

rule,  it  is   not  stationary  for  a  lono^  time  as  in  consecutive 
dementia,  but  progressive,  and  ending  more  rapidly  in  death. 

Insanity  of  Masturbation. 

Masturbation,  or  self-abuse,  was  an  evil  of  ancient  as  well 
as  modern  times.  The  Bible  gives  the  first  example,  whence 
the  term  Onanism.  The  practice  of  masturbation  if  persisted 
in  is  usually  regarded  as  evidence  of  neurotic  inheritance  ; 
but  it  is  probable  that  its  indulgence  is  more  extensive  than 
among  the  merely  neurotic,  and  that  many  cases  of  this 
secret  vice  are  found  out  of  asylums.  One  medical  man  who 
had  become  temporarily  insane  confessed  to  this  habit,  and 
without  any  qualms  of  conscience,  or  any  sense  of  shame, 
defended  it  on  physiological  grounds. 

It  is  exceedingly  common  in  the  insanities  of  puberty  and 
adolescence  ;  in  the  first,  and  perhaps  also  in  the  premonitory, 
stage  of  general  paralysis ;  it  is  sometimes  noticed  in  puerperal 
insanity ;  but  probably  it  results  in  the  latter  from  peripheral 
irritation,  for  it  is  indulged  only  temporarily.  According  to 
Yellowlees  and  others,  it  is  frequently  observed  in  epileptics ; 
but  I  cannot  confirm  this  statement  beyond  the  fact  that  it 
is  practised  by  epileptic  idiots  and  imbeciles,  and  sometimes 
unconsciously  when  waking  out  of  the  post-epileptic  stupor. 

Masturbation  is  much  more  common  among  males  than 
females,  and  this  is  what  might  be  expected.  It  may  be 
that  among  women  of  the  indolent  class  masturbation  is 
more  common  than  I  have  known  it ;  but  experience  of  the 
two  sexes,  so  far  as  I  have  learned  from  others,  is  emphatically 
that  of  Trousseau,  who  held  that  the  sexual  craving  is  feebler 
in  women  than  in  men.  It  is  more  difficult  to  discover  the 
female  masturbator,  and  she  is  more  likely  to  be  detected  by 
a  certain  gross  sensual  expression  and  physiognomy  before 
the  practice  is  discovered. 

As  far  back  as  1861,  Dr.  Peel  Ritchie  made  a  very  elaborate 
inquiry  regarding  masturbation  '  as  a  frequent  cause  of  in- 
sanity,' and  communicated  his  results  to  the  Lancet.  The 
basis  of  his  investigation  was  the  case-books  of  Bethnal 
House  Asylum  for  the  preceding  fifteen  years,  and  the  inquiry 
dealt  with  a  total  of  1,345  niale  patients.     The  propensity 


INSANITY  OF  MASTURBATION 


was  found  to  exist  in  8*84  per  cent.  — 12'52  per  cent,  for 
private  patients,  and  6'59  per  cent,  for  pauper  patients. 
The  census  among  pauper  patients  in  my  experience  is 
larger,  being  12  per  cent. 

Of  either  class  it  was  found  that  nearly  two-thirds  became 
insane  before  the  age  of  twenty-five.  As  regards  occupation, 
it  was  found  that  indoor  occupations  supply  a  larger  propor- 
tion of  patients  than  outdoor.  Contrary  to  what  might  be 
expected,  the  town  furnished  more  cases  than  the  country. 

The  more  frequent  the  practice  and  the  deeper  the 
hereditary  taint,  the  greater  the  chance  of  insanity  coming 
on  ;  but  we  find  in  many  cases  that  other  causes  are  at  work 
also — heredity,  overstudy,  drink,  the  period  of  life,  etc.  We 
further  find  that  masturbation  is  a  symptom  which  appears 
during  an  acute  attack  of  insanity,  and  disappears  with  the 
first  signs  of  convalescence.  The  immediate  effects  of  vicious 
sexual  indulgence  are  physical  exhaustion  and  mental  indo- 
lence, and  only  when  recovery  takes  place  is  the  habit 
resumed.  Mental  excitement  is  often  associated  with  activity 
of  the  sexual  nisus,  and  collapse  and  quiescence  with  its 
abatement  or  suspension. 

If  masturbation  becomes  a  perpetual  habit,  we  find  the 
candle  burning  at  both  ends,  for  we  have  a  condition  of 
waste  (loss  of  semen  and  wear  of  the  nervous  system)  on  the 
one  hand,  and  a  weak,  irregular  digestion  (in  other  words, 
inefficient  repair)  on  the  other.  The  first  mental  signs  of  its 
evil  influence  are  depression  and  hypochondria.  The  vice 
necessarily  means  solitude  and  secrecy,  and  if  the  man  has 
any  moral  sense  at  all,  it  means  self-reproach  and  loss  of 
self-respect.  Whether  naturally  or  as  a  result  of  it,  the 
victim  is  introspective  and  chicken-hearted.  He  is  morbidly 
apprehensive  of  evil  befalling  him,  and  he  studies  his  symptoms 
and  is  the  prey  of  the  charlatan.  The  first  physical  signs  are 
anorexia,  atonic  dyspepsia,  breathlessness  and  palpitations, 
and  peculiar  head  sensations.  The  skin  is  pale  and  cold, 
the  circulation  sluggish,  and  the  blood  impoverished.  The 
body  is  easily  exhausted  and  very  susceptible  to  disease, 
such  as  phthisis,  boils,  skin  eruptions,  etc. 

As  time  goes  on,  mental  changes  are  still  more  noticeable. 


i82  CLINICAL  MANUAL  OF  MENTAL  DISEASES 


If  not  before,  there  are  now  noticed  a  shyness,  an  averted 
gaze,  perhaps  a  sulky  manner,  a  drooping  of  the  head,  a 
slovenly  gait,  and  not  infrequently  a  hang-dog,  stupid,  or 
sullen  expression.  The  skin  is  now  decidedly  pale,  and  the 
physical  symptoms  of  the  earlier  stage  more  pronounced. 
Sometimes  a  hectic  flush  is  seen  on  the  cheeks ;  the  eyes, 
which  may  flare  up  with  fire  during  excitement,  are  usually 
dull,  glazed,  and  expressionless  ;  the  pupils  are  dilated  and 
sluggish.  Muscular  softness  and  flabbiness  is  well  marked. 
The  patient  refuses  food  from  sickness  and  anorexia ;  the 
bowels  are  constipated  ;  the  urine  is  usually  diminished  in 
quantity,  pale,  and  of  low  specific  gravity. 

So  far  the  masturbator  may  escape  confinement  as  a 
lunatic,  but  he  is  now  dangerously  near  that  stage.  The 
mental  condition  in  the  state  known  as  insanity  of  mastur- 
bation, while  possessing  certain  characteristics,  discloses 
many  diversities  according  to  the  individual,  and  other 
causes  of  insanity  operating  along  with  masturbation.  The 
remaining  observations,  therefore,  must  be  taken  as  by  no 
means  exhaustive.  A  full  resume  is  out  of  the  question,  for 
masturbation  is  Hj^dra-headed  in  its  relations  and  manifesta- 
tions. 

The  mental  state  may  still  be  one  of  depression  and  hypo- 
chondria. The  loss  of  self-respect,  the  pitiful  self-reproach, 
in  some  is  a  most  unenviable  condition.  One  man  keeps 
repeating,  '  I'm  no  man  at  all;  I'm  no  man  at  all.'  Another 
man  tells  us  that  he's  not  '  John  Thomson  '  (John  Thomson 
is  his  name),  that  '  the  real  John  Thomson  is  a  decent  fellow, 
a  hard-working  man,  who  works  for  his  wife  and  bairns.'  It 
seems  as  if  some  men  have  been  forced  by  overmastering 
impulse  to  do  things  which  they  utterly  loathe,  and  do  not 
recognise  as  consistent  with  their  moral  identity. 

The  mental  depression  may  take  the  form  of  religious 
melancholia,  almost  amounting  to  frenzy ;  indeed,  in  some 
cases  a  frenzy  of  impulse  overcomes  them,  and  the  offending 
member  may  be  severed.  Suicidal  impulse  is  quite  within 
the  range  of  probability  with  such  cases.  The  mind  may 
dwell  on  the  religious  aspect  of  things,  and  be  coloured 
accordingly,  so  that  it  becomes  a  prey  to  religious  delusions 


INSANITY  OF  MASTURBATION 


— e.g.,  that  he  is  a  lost  soul,  that  God's  angry  frown  and 
stern  denunciation  are  being  manifested,  etc. 

Hypochondria  develops  apace  in  some  minds,  and  is  fed 
by  the  solitary  and  unsociable  habits  of  the  individual  who 
lives  within  himself,  and  is  selfishly  engrossed  with  his  own 
sensations,  imagined  or  real. 

Mental  excitement  of  a  violent,  impulsive  character  may 
break  out  at  any  time.  It  may  be  continuous  and  dependent 
on  other  causes  besides  the  direct  stimulus  of  masturbation  ; 
but  we  can  recognise  two  forms  due  directly  to  the  latter 
cause — one  holding  out  for  days,  the  other  an  immediate 
and  sudden  result  of  the  act  itself.  The  latter  is  often 
homicidal ;  a  revulsion  of  feeling  seems  to  take  place,  a 
swing  of  the  pendulum  the  other  way ;  an  insane  fury,  fierce 
and  irresistible,  possesses  the  man,  and  violence  is  the  result. 

Sexual  antipathy  is  freely  manifested  by  some,  and  silently 
nursed  by  others  ;  a  fierce,  unreasoning  hatred  of  the  other 
sex,  and  delusions  in  this  respect,  are  very  prevalent.  One 
man's  delusion  was  that  a  woman  and  her  daughter  put  him 
under  '  a  bleeding  spell  in  the  privates.'  Others  accuse 
women  of  '  sucking  their  blood,'  '  drawing  their  guts,'  etc. 

Changeableness  of  disposition,  restlessness,  want  of  fixity 
of  purpose,  are  also  characteristic  of  this  disease,  and  account 
for  vagaries  and  reactions  from  one  extreme  to  another 
which  are  associated  with  insanity  of  puberty  and  adolescence, 
and  have  their  origin  in  the  reduced  stability  of  the  nervous 
system  which  masturbation  is  in  large  measure  accountable 
for. 

The  excitement  manifested  is  often  purposeless,  a  mere 
noisy  verbigeration,  automatic  motor  excitement,  spurts  of 
energy,  and  vague  wandering  impulses.  As  interludes  come 
mean  treacherous  acts  of  violence,  with  no  apparent  con- 
sciousness or  recollection.  Sometimes  it  is  impossible  to 
resist  the  conclusion  that  the  patient  is  not  so  unconscious 
as  his  expression  indicates.  What  the  man  thinks  or  how 
much  he  mentalizes  no  one  knows.  Mischievous  propensities 
sometimes  break  out.  One  fellow  seemed  always  on  the 
watch  for  opportunities  to  irritate  and  annoy.  He  took 
delight  in  smearing  with  his  spit,  or  dirt  from  his  pockets 


i84  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

or  the  dustbin,  what  was  newly  cleaned  and  polished. 
When  the  dining-hall  had  been  freshly  painted,  he  smeared 
the  ceiling  with  meat  and  potato,  which  stuck  fast  in  the 
wet  paint. 

Hallucinations  are  particularly  common  in  these  cases, 
sometimes  suggested  by  fear  or  suspicion,  but  often  the 
result  of  nervous  depression.  They  especially  exist  in  rela- 
tion to  sight  and  hearing.  They  are  not  always  displeasing, 
but  it  may  be  taken,  nevertheless,  as  correct  that  pleasing 
hallucinations  are  in  the  minority.  One  silent  fellow  who 
never  speaks  intelligently,  and  rarely  can  answer  a  question, 
stops  suddenly  in  his  work  in  response  to  hallucinations,  and 
swears  at  some  imaginary  person,  angrily  ordering  him  to 
'  get  out  of  that.'  Another  hears  the  words  of  a  spell  being 
uttered  to  encompass  his  doom,  and  sees  women  laying  hot 
plates  on  his  breast. 

Many  other  symptoms  might  be  described,  but  as  the  role 
of  the  mental  symptoms  is  not  always  played  out  in  the 
same  way,  and  they  are  so  various  that  anything  approach- 
ing finite  description  is  impossible,  a  summing-up  of  further 
mental  changes  will  suffice.  Incoherence  is  well  marked  in 
many  when  the  disease  advances.  Inability  to  form  thoughts 
or  give  them  speech — a  cutting  abruptly  short  of  sentences 
which  begin  with  a  show  of  intelligence — this  is  very  notice- 
able :  the  thought  is  but  a  flash  in  the  pan,  and  the  man  no 
sooner  begins  to  utter  it  than  the  motor  energy  is  exhausted 
and  speech  fails.  There  is  here  all  the  evidence  of  advancing 
stupor,  which  ultimately  passes  into  dementia. 

The  physical  symptoms  become  more  marked  in  some 
cases,  while  others  improve  because  of  the  restraints  of 
asylum  discipline  and  a  regular  hygienic  life.  Refusal  of 
food  may  occur  early  from  utter  loathing  of  food,  or  from 
delusions  which  inhibit  desire  for  food  and  inhibit  digestive 
activity. 

I  would  here  refer  to  one  rare  type,  appearing  during 
adolescence,  in  which  masturbation  has  ceased,  and  extreme 
emaciation  and  exhaustion  have  rapidly  supervened,  progres- 
sive atrophy  going  on  for  a  time,  then  physical  recovery,  but 
not  mental.     In  four  such  cases  a  low  type  of  inflammation 


INSANITY  OF  MASTURBATION  185 

over  one  knee-cap  came  on  (the  result  of  prolonged  attitudes 
of  prayer  and  supplication).  In  one  case  a  gangrenous  slough 
shelled  out  from  it,  and  the  patient  is  now  physically  well, 
and  has  resumed  his  vicious  indulgence.  In  other  cases  the 
trophic  neurosis  shows  itself  in  the  form  of  small  superficial 
ulcers,  usually  in  the  neighbourhood  of  joints  (the  shoulders 
and  toes  have  been  so  affected),  but  the  prognosis  is  not  so 
good  in  such  cases. 

The  masturbator  is  unsociable,  lies  long  in  bed,  especially 
avoids  the  opposite  sex,  and  frequents  the  water-closet  or 
some  dark  corner  where  he  can  pursue  his  evil  deeds.  The 
masturbator  who  begins  the  practice  in  middle  life  is  not  such  a 
degenerate,  and  not  quite  so  unsociable,  though  he  may  have 
sufficient  shame  to  prevent  his  exhibition  of  any  self-assertion. 

In  concluding  this  subject  I  must  strongly  emphasize 
the  importance  of  recognising  that  m.asturbation  may  be 
a  cause  of  violence,  excitement,  or  escape.  The  act  of 
masturbation  is  attended  with  an  appreciable  rise  of  tempera- 
ture, varying  from  one  to  two  degrees  in  the  first  half  hour. 
The  excitement  physically  is  often  considerable,  and  it  will 
be  found  on  inquiry  that  usually,  but  not  always,  some  form 
of  mental  excitement  follows  the  act.  It  may  take  the  form 
of  immediate,  sudden,  blind  fury  ;  whether  in  obedience  to 
hallucinations  or  pure  impulse  it  is  not  always  easy  to 
say.  It  may  take  the  form  of  excitement,  a  state  of  unrest, 
rhythmic  movements  of  apparently  automatic  character,  or, 
lastly,  the  act  of  masturbation  may  and  does  frequently  lead 
up  to  attempts  to  escape,  either  from  a  feeling  of  restraint 
and  oppression,  a  desire  for  freedom,  or  as  a  mere  act  of 
motor  excitement. 

The  treatment  of  masturbation  may  be  successful  if  there 
is  moral  strength  left  in  the  patient,  or  if  he  is  young,  and 
not  really  dominated  by  the  exercise  of  this  passion ;  but  in 
many  cases  when  it  comes  under  medical  notice,  the  passion 
has  become  a  second  nature,  and  there  is  little  hope.  Re- 
moval of  the  testicles  and  ovariotomy  have  been  unsuccess- 
ful, and  the  only  possible  remedy  in  such  cases  would  be 
division  in  the  male  of  the  sensory  nerve  of  the  penis,  and  in 
the  female  an  operation  analogous  thereto. 


i86  CLINICAL  MANUAL  OF  MENTAL  DISEASES 


The  evil  habit  is  increased  by  stimulants  and  certain 
foods.  For  those  who  are  too  susceptible  to  the  sexual 
craving,  milk  diet  is  prescribed.  Being  curious  to  know 
whether  meat  diet  really  was  more  stimulating  than  milk, 
I  subjected  three  male  masturbators  of  the  most  confirmed 
and  vicious  character  to  a  series  of  dietetic  experiments, 
consisting  of  a  dinner  of  either  (i)  meat,  (2)  fish,  (3)  Irish 
stew,  or  (4)  rice,  milk,  and  fruit  tart.  After  the  first  three 
diets  these  patients  frequently  masturbated,  but  in  no  case, 
so  far  as  I  could  learn,  after  rice,  milk,  and  fruit  tart,  which 
had  been  given  twenty-three  times.  Whatever  difference  of 
opinion  may  prevail  as  to  certain  articles  of  diet  being  stimu- 
lating to  sexual  function,  and  others  non-stimulating,  my 
investigations  have  strongly  confirmed  me  in  the  opinion 
that  regulation  of  the  diet  is  a  matter  deserving  of  careful 
attention. 

Moral  Insanity. 

Synonyms  :  Moral  Imbecility,  Reasoning  Insanity  (Folie 
Raisonnante),  Affective  or  Emotional  Insanity.  This  form 
has  been  regarded  by  many,  especially  by  lawyers,  as 
mythical.  There  is  a  natural  anxiety  lest  the  admission  of 
this  term  into  medico-legal  use,  and  the  acceptance  of  it  as 
signifying  an  actual  fact,  should  create  a  loophole  of  escape 
for  criminals,  and  especially  those  of  a  villainous  type. 

The  late  Dr.  Hack  Tuke,  in  his  '  Dictionary  of  Psycho- 
logical Medicine,'  has  not  taken  up  an  absolute  position  pro 
or  con.  He  first  gives  the  definition  of  Prichard,  viz.,  '  a 
disorder  which  affects  the  feelings  and  affections,  or  what  are 
termed  the  moral  powers  in  contradistinction  to  those  of  the 
understanding  or  intellect.'  Dr.  Tuke  in  answer  to  these 
legal  opponents  of  the  doctrine  of  moral  insanity  quotes 
Herbert  Spencer's  statement,  that  in  the  higher  evolution  of 
feeling  (the  moral  nature)  an  arrestment  may  occur  which, 
leaving  the  intellect  and  lower  emotional  nature  intact, 
results  in  moral  imbecihty  alone,  or  in  a  waywardness  of 
moral  conduct  from  youth  upwards  without  marked  disorder 
of  intellect. 


MORAL  INSANITY  187 

The  complex  relations  of  the  mental  powers  is  such  that 
it  would  be  hazardous  to  dogmatize  in  the  matter,  and  while 
both  Clouston  and  Savage  accept  moral  insanity  as  a  fact 
per  se  without  hesitation,  the  following  propositions  of  Hack 
Tuke  may  be  taken  as  very  carefully  hedging  the  application 
of  the  term,  although  the  fact  of  the  existence  of  such  a 
disease  as  moral  insanity  is  not  disputed :  (i)  The  higher 
levels  of  cerebral  development  which  are  concerned  in  the 
exercise  of  moral  control,  i.e.,  'the  most  voluntary'  of 
Hughlings  Jackson,  and  also  '  the  altruistic  sentiments  '  of 
Spencer,  are  either  imperfectly  evolved  from  birth,  or, 
having  been  evolved,  have  become  diseased  and  more  or  less 
functionless,  although  the  intellectual  functions  (some  of 
which  may  be  supposed  to  lie  much  on  the  same  level)  are 
not  seriously  affected,  the  result  being  that  the  patient's 
mind  presents  the  lower  level  of  evolution  in  which  the 
emotional  and  automatic  have  fuller  play  than  is  normal. 
(2)  No  doubt  it  is  difficult  to  lay  down  rules  by  which  to 
differentiate  moral  insanity  from  moral  depravity.  Each 
case  must  be  decided  in  relation  to  the  individual  himself, 
his  antecedents,  education,  surroundings,  and  social  status, 
the  nature  of  certain  acts,  and  the  mode  in  which  they  are 
performed,  along  with  other  circumstances  fairly  raising  the 
suspicion  that  they  are  not  under  his  control. 

The  most  frequent  departures  from  the  normal  moral 
character  are  to  be  found  in  the  young  and  adolescent,  and 
such  departure  is  a  characteristic,  frequently,  of  hereditary 
mental  degeneration.  Moral  imbecility  is  a  term  which  may 
be  applied  to  those  who  never  have  risen  to  an  average 
moral  and  intellectual  standard,  while  the  term  moral 
insanity  should  be  applied  to  all  cases,  whether  inherited  or 
not,  in  which  moral  degeneracy  is  the  prominent  unique 
symptom. 

The  pace  of  moral  evolution  varies.  Some  children  are 
precocious  in  this  respect,  and  decidedly  deficient  later  on, 
while  those  who  are  slow  to  make  progress  in  moral  de- 
velopment at  first,  often  arrive  at  a  higher  moral  standard 
later.  Some  apparently  bright  children,  whose  intellectual 
capacity  is  quite  up  to  the  average,  exhibit  a  moral  defect 


i88  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

right  through  hfe  ;  and  just  as  some  people  laugh  when  they 
should  cry,  and  cry  when  they  should  laugh,  their  emotional 
connections  being  transposed,  so  some  people  confound 
falsehood  with  truth,  and  never  understand  that  there  is  any 
such  thing  as  a  moral  significance  in  truth  or  falsehood, 
stealing,  cruelty,  or  disregard  of  parents. 

We  know  and  meet  every  day  of  our  lives,  members  of 
families  who  are  the  so-called  black  sheep,  who  reap  where 
they  have  not  sown,  and  are  entirely  devoid  of  the  altruistic 
sentiment  which  has  regard  to  others  as  well  as  to  ourselves. 
Some  we  know,  perhaps,  who  have  broken  nearly  all  the 
commandments  of  the  decalogue,  whose  ability  is  un- 
doubted, but  applied  to  ignoble  ends.  Are  such  morally 
insane  ?  Every  case  must  be  judged  on  its  merits.  We 
ma}'  answer  for  some  in  the  affirmative ,;  for  others  we 
can  be  justified  only  in  sa3'ing  that  they  are  borderland 
cases. 

In  helping  to  decide,  we  may  look  at  the  matter  in 
this  light.  What  was  gained  by  such  action  or  conduct  ? 
and  how  was  the  offence  committed  ?  The  lie  may  not 
have  been  worth  telling,  for  all  that  could  be  gained.  Some 
people  tell  lies  knowing  it  to  be  wrong,  but  their  instinctive 
nervous  dread  has  become  a  second  nature  from  childhood. 
Others  tell  lies  without  any  moral  sense,  and  for  the  most 
trivial  faults.  Some  steal  utterly  useless  articles,  openly, 
without  any  sense  of  wrong-doing,  and  as  generously  give 
them  away  to  the  first  person  they  meet.  The  sin  of 
covetousness  is  one  phase  of  original  sin,  though  it  may  not 
be  pronounced  in  the  majority;  but  the  desire  for  possession 
of  what  does_  not  belong  to  us  is  sometimes  a  very  active 
impulsive  affection  which  leads  to  acts  of  kleptomania  with 
no  other  evidence  of  insanit}-. 

Evidence  of  moral  breakdown  or  perversion,  especially 
deceitfulness,  is  manifested  frequently  in  the  victims  of 
intemperance,  whether  due  to  alcohol,  opium,  or  other 
narcotics  ;  and  here  we  have  often  an  example  of  pure  moral 
insanity  artificially  induced,  the  intellect  being  frequently 
intact,  though  eventually  it  is  obscured  by  the  long-continued 
and    excessive    use    of  these    poisons.      There    is    no    more 


IMPULSIVE  INSANITY  189 


remarkable  proof  of  the  moral  degeneracy  induced  by  drugs 
than  in  opium-smokers. 

As  a  rule,  it  may  be  stated  there  is  rarely  a  distinct 
reasonable  and  adequate  purpose  to  be  served  by  the  moral 
offences  of  such  patients,  and  as  the  questions  of  motive  and 
purpose  are  terms  which  a  lawyer  can  understand,  they  are 
competent  questions  for  us  to  consider  in  deahng  with  cases 
of  moral  insanity. 

Impulsive  Insanity. 

From  the  consideration  of  moral  insanity  we  are  naturally 
led  to  the  study  of  insane  impulses,  which  are  frequently  the 
outward  manifestation  of  moral  defect  or  degeneration,  but 
not  always  so.  Impulsive  acts  often  bring  the  culprit  within 
reach  of  the  law,  and  over  the  allegation  of  insanity  in  these 
cases  very  great  and  unseemly  wrangling  occurs  from  time 
to  time.  The  natural  attitude  of  the  judge  is  that  a  man  is 
presumed  to  be  sane  until  he  is  proved  msane,  and  there  is 
nothing  in  the  act  itself  to  decide  in  the  negative.  In  some 
cases  the  only  defence  possible  is  irresistible  insane  impulse ; 
but  no  lawyer  will  accept  this  alone,  and  all  the  evidence 
direct  and  subsidiary,  some  of  it  perhaps  rather  far-fetched, 
that  can  be  piled  up  is  produced  for  the  defence.  Into 
medico -legal  questions  we  shall  enter  more  particularly 
later  on. 

What  we  must  here  take  into  account  is  the  nature  of 
insane  impulses,  and  their  associated  nervous,  mental,  or 
moral  aberrations.  Insane  impulses  may  be  those  of  self- 
mutilation,  suicide,  homicide,  sexual  perversion  or  excess, 
destructiveness,  kleptomania,  pyromania,  dipsomania,  etc. 

The  patients .  most  liable  to  these  impulses  are  idiots, 
imbeciles,  epileptics,  and  masturbators,  who  especially  mani- 
fest sudden  outbreaks  of  anger  and  violence,  destructiveness 
of  furniture  or  clothing,  self-mutilation  or  sexual  perversion. 
The  best  example  of  pure,  irresistible  impulse  is  seen  in 
the  homicidal  attacks  of  the  epileptic  paroxysm,  sometimes, 
indeed,  without  paroxysmal  excitement  at  all.  Here  there 
is  blind,  unreasoning  fury,  though  it  is  well  known  that 
epileptics  may  deliberately  plan  a  murder. 


I90  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

It  is  often  ver}-  difficult,  even  impossible,  to  arrive  at  a 
physiological  explanation  of  impulse,  and  this  especially  with 
destructive  patients.  The  destructive  impulse  is  seen  in 
idiots  and  imbeciles,  in  mania,  general  paralysis,  and  in 
dementia.  It  suggests  a  reversion  to  a  lower  type,  in  which 
destructiveness  is  predominant,  and  in  which  the  constructive 
idea  has  not  been  appreciably  developed. 

The  irresistible  impulses  of  most  serious  import  are  the 
suicidal  and  the  homicidal,  and  they  may  be  taken  together. 
In  the  same  patient  the  one  may  succeed  the  other,  and 
this  is  true  of  irresistible  impulse  following  on  masturbation 
and  alcoholic  excess.  It  is  a  safe  rule  to  take  for  guidance, 
that  where  there  is  mental  depression,  or  hallucinations  of 
hearing  of  a  commanding  character,  suicide  should  be  pre- 
pared against.  Homicidal  impulse  is  often  an  immediate 
sequel  of  sexual  disturbance — menstruation,  masturbation, 
or  sexual  excess.  At  such  times  an  explanation  might  be 
difficult  to  obtain  :  the  man  who  has  done  the  deed  seems 
oblivious  ;  but  if  he  were  conscious,  or  had  any  recollection 
whatever,  it  will  often  be  found  that  a  strong  sexual  antipathy 
has  arisen  after  the  sexual  act.  Homicidal  attacks  are 
common  under  the  influence  of  alcohol,  and  also  as  a  sequel 
to  epileptic  seizures,  though  sometimes  without  seizures  and 
from  sheer  high-strung  nervousness  and  sensory  irritability. 
In  this  latter  state  the  gentle  rubbing  of  shoulders  against 
him,  the  most  apologetic  contradiction,  will  rouse  the  impulse, 
like  a  spark  to  gunpowder. 

The  sexual  appetites  are  sometimes  impulsive  to  an  un- 
accountable degree,  especially  under  alcoholic  stimulation, 
and  the  victims  of  masturbation  when  interfered  with  in  the 
midst  of  its  indulgence  are  often  very  dangerous.  Sexual 
desire  becomes  an  irresistible  impulse  in  many  reputedly 
sane,  but  in  senility  there  is  a  rejuvenescence,  and  it  may 
assume  then  a  distinct,  abnormal,  and  sometimes  most  de- 
praved character. 

Kleptomania  is  found  as  an  early  symptom  of  general 
paralysis,  and  as  an  occasional  symptom  without  any  other 
signs  of  mental  disease.  P3Tomania  is  found  to  be  a  symptom 
of  adolescent  insanity  and  puerperal  mania:  and  of  dipsomania 


IMPULSIVE  INSANITY  191 

it  need  only  be  said  here  that  it  is  a  disease  characterized  by 
a  periodical  recurrence  of  an  irresistible  craving  for  a  stimulant 
or  narcotic. 

Whatever  may  be  the  nervous  or  mental  condition  asso- 
ciated with  impulsive  seizures,  we  have  in  any  or  all  cases 
to  inquire  (i)  as  to  the  consciousness  of  the  individual  during 
and  after  the  attack,  the  degree  of  consciousness,  and  the 
after-memory  of  the  event;  (2)  as  to  his  usual  amount  of 
self-control,  and  as  to  his  personal  history  in  this  respect ; 
(3)   as  to  the  immediately  exciting  cause. 

In  some  cases  there  is  apparent  oblivion  during  the  act, 
as  much  as  in  a  state  of  somnambulism.  In  others  there 
appears  an  evident  and  strong  purpose,  as  in  the  remarkable 
case  published  by  the  late  Dr.  McLaren,  of  Larbert  {Medical 
Times  and  Gazette,  January,  1876),  and  quoted  by  Dr.  Clouston. 
Here  there  were  apparently  alternations  of  mental  condi- 
tion, the  one  melancholic  or  rational,  and  the  other  without 
warning,  destructive,  violent,  homicidal  and  suicidal.  Dr. 
McLaren  described  and  analyzed  this  case  with  remark- 
able lucidity  and  skill,  and  his  opinion  was  that  it  was 
closely  suggestive  of  epilepsy,  and  that  the  impulsive  state 
was  one  of  a  new  or  altered  consciousness.  It  frequently 
happens  that  the  act,  and  the  idea  or  hallucination,  if  any, 
which  prompted  it,  leave  no  impression  on  memory,  so  that 
there  is  a  disposition  to  believe  in  a  pure,  blind  impulse. 
The  more  the  subject  is  penetrated,  the  more  we  have 
revealed  the  fact  that  the  impulse  is  a  psycho-motor  act, 
though  the  psychic  equivalent  may  often  be  forgotten  or 
unrevealed. 

The  second  matter  of  inquiry  is  the  individual's  usual 
amount  of  self-control.  There  is,  perhaps,  no  perfect  self- 
control,  though  some  men  are  so  gifted  in  a  pre-eminent 
degree,  even  if  their  impulses  to  speech  and  action  are  at  all 
active.  Self-control  is  largely,  though  not  entirely,  a  matter 
of  training  and  habit,  and  much  depends  on  '  sowing  an  act 
and  reaping  a  habit,  sowing  a  habit  and  reaping  a  character.' 
Idiots  and  imbeciles  and  spoiled  children,  the  former  mostly 
from  congenital  or  infantile  mental  defect  and  superadded 
inefficient    training,   the    latter    from    indulgent   upbringing. 


192  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

manifest  early  an  absence  of  self-control.  In  addition  there 
are  many  so-called  degenerates  whose  mental  equipoise  is 
most  unstable,  and  who  break  out  in  fits  of  temper  or 
excesses  of  various  kinds  on  the  very  slightest  provocation. 
To  prick  the  skin  may  excite  a  blow  from  one  man,  and 
only  a  faint  facial  contortion  from  another.  You  must  here 
take  into  account  excitability  of  nerve,  as  well  as  degree  of 
self-control. 

Third,  the  immediately  exciting  cause  may  be  external 
or  internal.  It  may  be  due  to  a  thoughtless  word,  a  word 
misconstrued,  a  push,  or  the  summation  of  irritating  stimuli 
such  as  the  sound  of  many  voices  or  of  noisy  clatter.  It 
may  be  due  to  visual  sensations  of  an  alarming  character, 
to  fright,  or  to  acute  sensory  disturbances,  such  as  neuralgia, 
congestive  headache,  etc.  Mentally,  suspicion,  delusions  of 
persecution  and  the  like,  intense  depression  on  the  one  hand, 
or  angry  irritability  on  the  other,  or  finally  hallucinations, 
may  be  the  spark  which  excites  explosion. 

Clinical  Illustrations. 

A  nergic  Stupor. 

J.  W.  This  }'oung  man  has  been  in  a  state  of  stupor  for 
some  time,  following  an  attack  of  acute  mania.  He  broke  a 
window  when  excited,  and  a  piece  of  flesh  was  cut  clean 
away  at  the  wrist.  It  was  a  long  time  in  healing,  and  during 
the  stupor  the  dressing  of  the  wound  was  not  attended  with 
pain,  though  when  he  recovered  mentally  he  was  quite 
sensitive  to  pain.  When  asked,  three  months  ago,  if  he 
remembered  the  accident,  he  said  he  did.  It  made  an 
impression  ;  but  he  remembered  nothing  else.  He  did  not 
require  to  be  fed,  but  was  inclined  to  sleep  over  meals,  and 
had  to  be  jogged  on  ;  he  was  dirty  in  his  habits.  He  had 
to  be  led  or  pushed  forward  ;  he  suffered  from  constipation. 
He  had  a  fair  appetite ;  the  pupils  were  dilated  and  sluggish. 
Asked  if  he  remembered  how  long  he  was  in  the  asylum,  he 
answered,  '  No.'  '  Do  you  remember  having  a  sore  hand?' 
'  Yes.'  '  What  was  the  matter  with  it  ?'  '  Influenza.'  '  You 
hadn't  influenza  of  the  hand,  had  you  ?'     '  I  don't  know.' 


CLINICAL  ILLUSTRATIONS  193 

He  is  slouching  in  gait,  not  resistive  to  any  movement,  but 
rather  passive.  There  is  no  impairment  of  circulation  ;  his 
weight  is  increasing ;   time  reaction  very  slow. 

After -note.  —  When    discharged   recovered,  he  could    not 
remember  anything,  except  the  accident  to  his  hand. 

Dementia.     {From  a  Clinical  Demonstration.) 

John  D.,  set.  30.     Tall,  well  built,  placid  expression. 

Q.  How  are  you  ? 

A.  Very  unquietly. 

Q.  What  is  the  matter  ? 

A.  Nothing  at  all. 

Q.   How  old  are  you  ? 

A.  Seventeen. 

Q.  How  long  have  you  been  here  ? 

A.  Six  months.     (He  is  here  a  year.) 

Q.  Where  did  you  come  from  ? 

A.  Away  down  the  coal  gum.  (He  is  a  collier,  but  has 
been  in  asylums  for  thirteen  years.) 

It  may  be  noticed  that  the  time  reaction  is  scarcely  retarded ; 
but  he  can  only  answer  simple  questions,  and  they  involve 
very  little  thinking  capacity.  His  memory  retains  something 
of  life's  impressions  up  to  the  time  he  became  insane,  but 
not  since. 

Masturbation. 

A.  B.,  aet.  32,  came  to  the  asylum  inquiring  after  a  situa- 
tion, as  he  felt  his  mind  strange. 

Notes  taken  at  the  time. — He  is  an  artisan,  feels  a  mental 
confusion,  and  an  inability  now  to  work  up  to  the  standard 
of  other  workmen,  which  has  depressed  him.  Confesses 
to  indulging  in  the  habit  of  masturbation,  but,  like  many 
such,  qualifies  his  statement  by  saying  that  he  has  given 
it  up.  Gave  up  a  girl  on  account  of  his  health  ;  is  tortured 
by  the  idea  that  he  is  not  competent  to  marry.  Pupils 
active,  left  larger  than  right.  Tongue  large  and  healthy 
in  appearance.  Complexion  good.  Physique  fair.  Father 
died  of  dropsy,  set.  64  ;  mother  of  surgical  ailment.  He  is 
slow  of  speech  and  thought,  nods  his  head  automatically 
when  told  anything,  like  a  Chinese  figure.     Does  not  seem  to 

13 


194  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

be  'acutely  conscious  of  what  is  said  to  him,  for  his  expres- 
sion is  rather  dreamy  and  indifferent. 

This  is  a  case  where  much  good  might  have  been  done  if 
the  man's  will  was  sternty  brought  to  bear  upon  his  character 
and  conduct.     I  never  saw  him  again. 

Case  of  Masturbation  and  Insanity  during  Adolescence. 

J.  B.,  5et.  20,  admitted  in  1887  after  a  year's  development. 
His  manner  was  very  peculiar  and  morose.  He  owned  that  he 
was  often  nearly  overpowered  by  mad  impulses  to  do  injury 
to  himself  and  others,  that  his  memory  had  become  very 
bad,  etc.  His  thoughts  were  much  confused,  and  he  couldn't 
settle  to  do  anything.  His  father  said  he  had  threatened 
to  put  a  knife  in  him,  that  he  had  not  worked  for  a  year, 
that  fifteen  months  before  admission  he  set  fire  to  a  church 

in   B and   some  stacks   at  a  farm    close    by,   and   that 

his  conduct  was  quite  furious.  He  could  with  difficulty  be 
got  to  answer  questions,  and  was  very  dull  and  apathetic. 
His  father  said  that  he  had  been  out  and  in  the  house  fifty 
times  in  one  day ;  sometimes  walked  quickly  up  and  down 
the  house,  apparently  furious.  Present  state  :  He  passes 
through  three  stages  in  his  mental  cycle — first,  fairly  well,  a 
premonitory  stage  of  a  few  days,  when  he  answers  questions, 
engages  in  some  employment,  and  is  more  active  in  his 
movements.  Second,  the  stage  of  active  masturbation  and 
excitement.  In  this  stage  he  talks  incoherently,  works  with 
energy  so  long  as  there  is  work  to  do,  masturbates  whenever 
he  gets  opportunity.  Is  restless  and  impulsive  if  compelled 
to  sit  down,  jumps  up  on  tables  and  chairs,  takes  his  food 
better  in  the  first  days,  but  not  after.  Third  stage,  quiet  and 
stupid ;  does  not  masturbate  ;  lasts  about  three  weeks. 

These  stages  recur  regularly  in  the  above  order,  but  there 
is  increasing  dementia  and  abolition  of  memory ;  even  the 
older  events  that  he  used  to  recall  promptly  are  blurred,  and 
often  quite  impossible  of  recollection. 

Moral  Insanity. 

J.  M.,  hawker,  set.  32.  This  man  was  sent  to  the  asylum 
by  the  police,  having  feigned  epileptic  insanity ;  he  feigned 


CLINICAL  ILLUSTRATIONS  195 

symptoms  according  to  the  role  he  wished  to  play — excitement, 
attracting  attention  in  the  streets,  delusions,  e.g.,  '  that  his 
fingers  were  mortified  '  ;  later,  '  that  he  was  a  gentleman  of 
great  gifts,'  and  epileptic  seizures,  which  he  feigned  with  some 
adroitness.  His  conversation  on  admission  was  quite  coherent, 
and  after  a  day  in  the  asylum  the  feigned  symptoms  disap- 
peared ;  he  was  tested  regarding  his  mental  faculties,  and  found 
to  have  the  power  of  attention,  observation  and  reasoning 
equal  to  the  average  man  of  his  class.  He  was  cunning,  how- 
ever, obsequious,  and  his  speech  and  conduct  were  marked  by 
duplicity.  Of  moral  sense  or  responsibility  he  was  absolutely 
deficient,  and  not  for  wife  or  family  did  he  evince  the  least 
concern.  When  it  suited  him  he  escaped,  and  the  next  I 
learned  of  him  was  from  the  newspapers,  which  related  the 
case  of  a  sham  epileptic,  who,  being  taken  for  the  real  Simon 
Pure,  was  removed  to  one  of  our  hospitals,  and  speedily 
found  out  and  discharged. 

Impulsive  Insanity.     (From  a  Clinical  Demonstration.) 

Suicidal  Impulse. — W.  B.,  set  21.  This  patient  talks  intelli- 
gently; he  looks  bright  and  mentally  active,  and  you  might 
pass  him  in  the  street  without  ever  suspecting  him  of  insanity. 
Since  his  admission  he  is  rather  quiet,  and  we  have  for  a 
long  time  been  at  a  loss  to  explain  the  sudden  impulses 
which  seize  him.  While  holding  him  as  I  do  now  by  the 
collar,  he  has  sprung  from  his  attendant  without  warning ; 
the  change  from  apparent  mental  composure  to  suicidal 
impulse  is  so  sudden  and  unexpected  as  to  suggest  sham- 
ming ;  but  there  is  no  sham  here.  We  have  been  able  to 
trace  his  acts  to  hallucination  of  hearing.  His  case  may  be 
summed  up  thus  :  Overstudy  and  anxiety  to  get  on  ;  neglect 
of  food  and  sleep.  Subjective  sounds  in  his  ears;  then 
groans  like  something  human  ;  later  voices ;  the  voices 
be.:ome  terrifying,  then  commanding,  until  at  last,  being 
distracted,  he  was  impelled  to  attempt  suicide  in  order  to 
escape  from  them. 

Two  cases  of  homicidal  impulse  may  be  described  in  a  few 
words  : 

13—2 


196  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

G.  B.,  set.  22,  stupor,  his  head  was  bhstered  with  slight 
effect ;  when  roused  to  take  food,  he  let  fly  the  plate  of  soup 
at  the  doctor's  face,  seized  a  knife  and  was  restrained  just  in 
time. 

H.  R.,  aet,  24,  had  delusions  of  persecution  ;  he  was  irritated 
by  the  supposed  sneers  of  those  beside  him,  lifted  a  chair 
over  his  head  and  brought  it  down  with  a  crash,  fortunately 
on  the  table,  not  on  the  intended  victim. 

Other  evidences  of  impulsive  sanity  are  seen  in  epileptics, 
general  paralytics,  cases  of  insanity  of  masturbation,  in 
puerperal  and  allied  insanities,  and  in  other  forms.  They 
will  be  referred  to  incidentally. 


CHAPTER  XI. 

GENERAL  PARALYSIS  OF  THE  INSANE. 

Is  it  a  distinct  clinical  and  pathological  entity? — Conflicting  views — Who 
are  most  liable  to  be  affected  ? — Age,  sex,  condition  as  to  marriage, 
heredity — Causation — Premonitory  Signs — These  must  be  taken  czan 
grano  —  The  typical  three  stages  which  were  formerly  described 
cannot  now  be  insisted  on — The  old  type  not  extinct,  and  it  is  here 
described  in  its  several  stages,  mental  and  physical — Mickle's  classifi- 
cation of  mental  groups— Physical  Signs— Differential  diagnosis  from 
Chronic  Alcoholic  Insanity — Syphilitic  Insanity  —  Insanity  from 
Cerebral  Softening,  or  with  concomitant  paralytic  affections — Acute 
Mania— Congestive  Epileptiform  and  Paralytic  seizures  intercurrent 
in  this  disease — Prognosis — Treatment — Clinical  illustrations. 

General  paralysis  of  the  insane  until  recently  was  regarded 
as  a  distinct  clinical  and  pathological  entity,  running  a  well- 
defined  course,  a  downward  general  paralytic  course,  and 
usually  ending  within  a  specified  time  in  death.  Dr.  T.  B. 
Hyslop,  writing  in  the  J otmtal  of  Mental  Science  (April,  i8g6), 
endeavours  with  considerable  effect  to  show  either  that  the 
term  '  general '  is  inadmissible,  or  at  least  that  its  diagnostic 
use  should  be  greatly  restricted.  In  taking  up  this  position, 
Dr.  Hyslop  is  to  a  certain  extent  in  agreement  with  the  late 
Monsieur  Ball  and  others,  who  have  directed  attention  to 
the  unsatisfactory  basis  of  our  present  diagnosis  of  this 
disease.  His  argument  is  that  many  are  cases  of  pseudo- 
general  paralysis,  e.g.,  alcoholic,  syphilitic,  saturnine  and 
other  insanities.  There  is  much  force  in  his  arguments, 
and  only  the  conservative  character  of  scientific  opinion  has 
prevented  a  fuller  acceptance  of  Dr.  Hyslop's  views.  The 
feeling  still  strongly  obtains,  that  there  is  recognisable  such  a 
pathological  and  clinical  genjis  as  general  paralysis  of  the 


198  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

insane,  and  that,  though  its  mental  course  is  rarely  so  loud 
and  grandiloquent  as  it  used  to  be,  it  is  essentially  the  same 
disease,  pursuing  a  downward  course,  perhaps  not  so  rapid, 
perhaps  with  longer  pauses  of  apparent  arrest,  but  none  the 
less  certain  to  end  in  death,  as  a  rule  within  three  or  four 
years. 

Dr.  Savage,  apropos  of  Dr.  Hyslop's  argument,  speaks 
thus  :  '  Cases  of  pseudo-general  paralysis  are  those  where  I 
had  made  a  mistake  in  diagnosis — cases  where  I  dogmatically 
said  a  patient  would  die  in  two  or  three  years,  and  they  are 
still  living  after  many  years.'  He  still  regards  general 
paralysis  as  a  name  that  must  be  applied  to  a  group  of 
symptoms,  but  believes  with  Dr.  Hyslop  that  many  cases 
frequently  regarded  by  this  name  should  be  relegated  outside 
of  it.  Dr.  Wiglesworth,  whose  careful  pathological  work 
entitles  him  to  speak  with  authority,  still  upholds  the  term, 
and  appears  to  differ  from  Dr.  Savage  in  the  inference  to  be 
drawn  from  the  above  quotation  that  general  paralysis  is 
necessarily  incurable.  The  discussion  of  Dr.  Hyslop's  paper 
{JoiLvnal  of  Mental  Science,  July,  1896)  gives  a  fair  precis  of 
the  views  at  present  held  on  the  subject. 

The  term  '  general '  has  different  meanings  in  the  minds 
of  various  asylum  physicians.  It  must  be  clearly  under- 
stood that  it  does  not  mean  complete  paralysis  of  the  whole 
muscular  system.  That  means  death.  The  aggregate  of 
cases  may  present  what  has  been  described  as  a  hotch-potch 
of  symptoms  and  pathology,  but  it  is  our  duty  to  differentiate 
to  the  best  of  our  ability  in  the  light  of  present  knowledge, 
and  so  long  as  we  cannot  resolve  from  chaos  particular  and 
definite  groups  of  symptoms,  and  label  them  distinctively, 
we  must  make  use  of  the  old  term,  and  restrict  its  applica- 
tion whenever  possible.  Just  as  we  now  differentiate  forms 
of  Bright's  disease,  phthisis,  and  morbus  cordis,  we  may 
hope  some  day  to  distinguish  more  clearly  several  forms  now 
grouped  under  the  head  of  general  paralysis  of  the  insane. 
We  make  use  of  the  full  term  '  general  paralysis  of  the 
insane,'  though  the  possibility  that  general  paralysis  such  as 
we  see  it  in  asylums — in  the  early  stage,  at  least — may  exist 
without  insanity  must  not  be  lost  sight  of. 


GENERAL  PARALYSIS  OF  THE  INSANE  ,1,99 

General  paralysis,  whether  due  to  a  vascular  or  degenera- 
tive disease,  or  both,  is  not  defined  by  impassable  limits 
either  in  the  cord  or  brain.  There  is  this  essentially  in  the 
pathology  of  the  disease — active  and  progressive  inroads  on 
fresh  territory  of  the  nervous  system.  It  may  be  so  insidious 
as  to  be  unnoticed  till  macroscopic  results  speak  for  them- 
selves ;  but  it  is  as  surely  progressive.  We  have  m.onoplegias, 
hemiplegias,  spinal  paralyses,  and  cerebral  palsies,  which  are 
dry  mortifications,  so  to  speak,  mere  dry  rotten  stumps,  but 
the  trunk  and  other  branches  are  physiologically  intact  still. 
In  general  paralysis  the  disease  is  constitutional,  not  partial, 
selective,  and  circumscribed. 

General  paralysis  of  the  insane  is  a  disease  of  civilized  life  ; 
it  is  the  penalty  which  we  pay  for  our  civilization,  the  proof 
of  our  rapidly  increasing  brain  evolution,  with  increase  of 
inental  excitants,  such  as  social,  sexual,  and  alcoholic  stimu- 
lants. We  do  not  find  general  paralysis  affecting  the  negro 
or  the  Celt  in  his  native  state,  but  transplant  him  to  a 
state  of  civilization  and  you  change  him  from  a  negative  to 
a  positive  state,  susceptible  to  the  disease.  He  may  drink 
as  much  whisky  as  he  likes  in  his  native  glens,  but  if  it  ever 
produces  insanity  it  does  not  take  the  form  of  general 
paralysis. 

The  causation  is  still  clouded,  and  has  given  rise  to  much 
speculation.  It  has  been  asserted  that  it  is  the  result  of 
excess,  chiefly  of  sexual  excess,  but  certainly  of  this  and 
alcoholic  excess  combined.  In  the  opinion  of  others,  the 
magnitude  of  these  causes  has  been  overstated,  and  it  is 
regarded  as  largely  the  result  of  severe  mental  strain,  pro- 
longed anxiety  and  worry,  and  a  state  of  feverish  mental 
excitement  from  day  to  day  with  few  pauses  for  holiday,  or 
recreation,  or  change  of  thought  of  any  kind.  It  is  asserted 
again  that  all  these  causes  I  have  mentioned  are,  taken  con- 
jointly, the  one  and  only  cause  of  general  paralysis.  Spitzka 
puts  it  down  to  the  three  W's — wine,  worry,  and  women. 

According  to  Dr.  Julius  Mickle,  the  male  sex  is  affected  in 
a  proportion  of  between  four  and  five  to  one  female,  and 
some  of  the  earlier  observers  attributed  this  to  a  prophy- 
lactic influence  of  the   menstrual  discharge  in   women,   but 


200  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

this,  as  Mickle  has  pointed  out,  is  fallacious.  Those  pre- 
disposed are  usually  of  a  sanguine  temperament,  according  to 
some  authorities,  but  this  is  certainly  putting  the  case  too 
strongly.  My  own  experience  is  that  the  bilious  or  bilio- 
sanguine  temperament  is  quite  as  liable  to  be  affected  in  this 
way.  No  certain  information  can  be  given  as  to  the  character 
and  disposition  of  those  predisposed  to  general  paralysis, 
because  the}-  are  so  various.  Hereditary  predisposition  is 
not  so  prominent  a  factor  as  in  other  forms  of  insanity,  but 
it  is  found  to  vary  in  the  statistics  of  different  countries,  and 
ma}'  be  stated  as  from  15. to  30  per  cent.  The  proportion  of 
married  general  paralytics  is  much  greater  than  unmarried. 
The  occupations  stated  by  Mickle  as  most  liable  are  the 
military  and  naval  services ;  occupations  exposing  to  great 
heat  and  sweating,  or  to  alternate  draughts  of  heat  and  cold, 
prostitution,  occupations  which  entail  emotional  strain,  con- 
stant worry  and  irritation  or  intellectual  overwork,  as  the 
occupations  of  professional  and  literary  men.  Of  predis- 
posing conditions  there  is  the  ambitious  life,  with  its  prolonged 
strain,  its  iiuctuation  of  feeling,  prolonged  or  violent  feelings 
or  passions,  whether  of  worry,  indignation,  or  lust.  A  previous 
attack  of  insanity  or  cranial  injuries  may  predispose  to  this 
disease.  It  sometimes,  though  rarely,  breaks  out  in  women 
during  pregnancy,  or  in  the  puerperal  state,  these  conditions 
being  exciting  causes. 

It  is  difficult  to  distinguish  predisposing  from  exciting 
causes,  for  you  will  find  that  the  predisposing  often  operates 
all  along  the  line,  and  that  what  are  known  as  exciting 
causes,  sexual  excess,  alcoholic  excess,  sunstroke,  cranial 
injuries,  etc.,  are  also  often  predisposing  as  well.  You  may 
find  that  too  much  has  been  attributed  to  sexual  excess  or 
alcoholic  excess.  In  Germany  it  is  even  asserted  that 
syphilis  is  the  chief  cause  of  general  paralysis.  The  sexual 
excess  and  the  alcoholic  excess  may  be  preliminary  symptoms 
rather  than  causes,  and  syphilis  produces  many  forms  of 
insanity,  and  is  by  no  means  so  frequently  a  cause  of  general 
paralysis  as  has  been  asserted.  My  experience  lately  has 
been  that  general  paralysis  in  the  female  is  often  the  result 
of  syphilis. 


GENERAL  PARALYSIS  OF  THE  INSANE  201 

Premonitory  Symptoms. 

Much  has  been  written  about  the  premonitory  symptoms, 
and  there  is  a  natural  temptation  to  lay  stress  on  these.  It 
is  very  gratifying  to  forecast  early  the  diagnosis  and  course 
of  such  a  disease,  but  attempts  at  early  diagnosis  are  often 
attended  with  most  unfortunate  results.  The  following 
statement  of  premonitory  symptoms  must  be  taken  ctmi 
grano,  for  their  significance  is  not  always  the  same,  and  if 
too  much  rehance  is  placed  on  them,  a  hasty  prognosis  and  a 
wrong  one  may  be  the  result.  Such  symptoms  should  be  taken 
as  indications  for  more  exhaustive  investigation,  but  a  '  non- 
committal'  attitude  of  mind  is  necessary  till  time  reveals  their 
true  significance.  There  is  not  one  of  the  following  symptoms 
that  may  not  be  purely  functional,  and  unrelated  to  general 
paralysis  in  the  remotest  degree. 

There  is  therefore  a  degree  of  uncertainty  in  the  general  pre- 
monitory forecast  of  general  paralysis.  We  have  to  regard 
it  as  a  nervous  and  a  mental  disease,  the  nervous  symptoms 
perhaps  progressing  in  advance  of  the  mental,  or  the  mental 
in  advance  of  the  nervous.  If  you  ask  the  friends  of  a 
patient  how  long  he  has  been  affected  with  this  disease,  they 
will  tell  you  a  few  weeks,  and  that  is  so  from  their  point  of 
view;  but  they  cannot  nicelydiscriminate  changes  of  character, 
and  they  are  ready  to  make  excuses — ■'  to  his  faults  a  little  blind, 
to  his  virtues  very  kind.'  The  extra  dissipation  is  excused  on 
the  score  of  overwork,  or  justified  by  the  fond  wife  or  sister  in 
some  other  way.  The  greater  restlessness,  the  larger  ambition, 
the  bolder  schemes,  the  wilder  imaginations,  are  but  signs  of 
increasing  maturity  and  masculine  genius.  Nevertheless,  a 
trained  observer  will  notice  fine  departures  from  health,  for 
general  paralysis  will  show  itself  in  its  early  stages  to  an 
acute  physician  long  before  it  is  noticed  by  the  friends — 
mental  defects  of  a  kind  not  easily  noticed,  because  they  are 
only  apparent  to  intelligent  observers.  There  is  a  steady 
and  more  or  less  regularly  progressive  degeneration  of  mind 
and  body,  so  that  the  highest  faculties  show  the  first  signs  of 
change,  and  the  special  attamments  fail  before  the  more 
general.     The  pace  of  degeneration  may  be  rapid  or  slow. 


202  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

and  it  is  often  insidious.  The  mental  and  nervous  downfall 
usually  goes  on  by  almost  imperceptible  gradations,  the  finer 
adaptations  failing  first.  That  is  one  form  of  onset.  In  other 
cases,  however,  we  may  have  a  sudden  apoplectiform  attack 
followed  by  stupor  or  a  sudden  attack  of  acute  mania  without 
any  appreciable  mental  or  neurotic  warning.  You  may  notice 
also  slight  motor  defects  coming  and  going  for  years,  showing 
a  degree  of  motor  instability.  You  may  find  an  increasing 
muscular  fatigue  on  exertion,  or  temporary  and  recurrent  affec- 
tions of  speech;  but  you  must  be  careful  to  differentiate  between 
what  is  rheumatic  or  gouty  (weakness  in  legs),  and  what  is 
paresis,  and  you  must  inquire  into  the  speech  history  of  the  in- 
dividual, who  perhaps  was  affected  in  childhood  or  youth  with 
a  stutter  or  some  other  defect.  Other  prodromata  are  seizures 
of  cerebral  congestion,  flushing  and  heat  of  the  face  and 
head,  'stunnings,'  or  'absences' — especially  after  excitement 
or  overwork — headache,  somnolence,  ptosis,  diplopia,  facial 
palsy,  affections  of  hearing  and  sight  coming  and  going. 
Intellectually  there  may  be  manifested  mistakes  in  writing  and 
speaking,  missing  out  a  word,  using  the  wrong  word,  misspell- 
ing, forgetfulness,  fitfulness  and  irregularity  in  business  or  ex- 
pensiveness,  a  speculative  change  of  character,  and  insomnia. 
On  the  other  hand  there  may  be  depression  and  worry  and 
a  gloomy  forecast.  Sometimes  we  notice  excess  in  eating  and 
drinking,  and  perversion  of  the  moral  sense  is  a  common 
symptom.  Temporary  loss  of  sight  and  optic  neuritis  are  also 
among  the  most  important  of  the  premonitory  symptoms. 

The  typical  three  stages  of  the  disease  which  were  formerly 
described  must  no  longer  be  insisted  on.  General  paralysis 
is  less  typical  than  it  used  to  be.  Just  as  the  types  of  fever 
have  changed,  in  like  manner  the  classic  description  of 
general  paralysis  is  admissible  for  only  a  few  of  the  cases 
which  we  meet  with  in  practice  to-day.  The  analogy  goes 
further.  It  used  to  be  the  general  opinion  that  fevers  and 
inflammations  were  sthenic,  and  therefore  bleeding  was  in- 
dicated. The  reason  given  by  some  of  the  older  physicians 
for  the  change  from  bleeding  to  feeding  was  that  the  type  of 
disease  had  changed.  The  type  of  general  paralysis  fifteen 
or  twenty  years  ago  was  noisier,  more  self-assertive,  abound- 


GENERAL  PARALYSIS  OF  THE  INSANE  203 

ing  in  excitement  and  active  extravagance  of  speech  and 
conduct,  and  exhibited  physically  a  full-blooded  sthenic 
appearance  more  rarely  seen  now.  Congestive  attacks,  the 
so-called  apoplectiform  attacks,  epileptiform  attacks,  were 
much  more  common,  and  sudden  extensive  muscular  paralysis 
as  a  result  of  them.  Now  it  does  seem  as  if  degenerative 
changes  and  negative  symptoms  were  more  frequent,  and  the 
manifestation  of  the  disease  in  its  first  appearance  less 
robust,  the  general  paralytic  being  often  a  puerile  weakling 
from  the  beginning  of  his  malady.  It  must  not  be  supposed 
that  the  old  type  is  entirely  extinct,  and  as  its  description 
gives  more  graphically  the  conception  of  what  is  possible, 
but  is  not  always  in  evidence,  I  propose  to  still  repeat  this 
description.  There  are  recognisable  in  such  cases  three 
fairly  well-marked  stages :  (i)  The  stage  of  excitement, 
(2)  the  stage  of  quiescence  or  transition,  (3)  the  stage  of 
dementia  and  advanced  paralysis ;  but,  as  already  indicated, 
there  are  exceptions,  and  as  there  are  different  types  of  general 
paralysis,  these  stages  are  modified  according  to  the  type. 

In  the  stage  of  excitement  the  mental  side  of  the 
disease  is  the  predominant  one  ;  the  motor  advances  more 
slowly,  and  is  usually  not  recognisable  at  first  without  a 
little  experience  and  education.  The  excitement  is  usually 
of  the  maniacal  type,  and  you  will  most  likely  at  first 
diagnose  such  a  case  as  one  of  acute  mania.  There  is 
exaltation  of  feeling,  evidenced  by  a  gay,  boisterous,  happy 
expression.  The  sense  of  well-being  is  exaggerated,  every- 
thing is  couleur  de  rose ;  the  patient  is  absurdly  happy  and 
contented  with  himself  and  his  surroundings;  there  is  no  sign 
of  depression,  no  anxiety,  no  care  and  no  thought  for  the 
future.  The  moral  sense  is  decidedly  blunted,  and  you  will 
find  that  often  one  of  the  first  signs  of  the  onset  of  this 
disease  is  that  the  patient  has  been  taken  up  for  theft,  and 
he  may  be  committed  to  prison  without  the  authorities 
detecting  anything  wrong.  This  thieving,  or  kleptomania,  is 
a  notable  symptom,  for  the  patient  takes  away  things 
openly  ;  has  been  known  to  remove  articles  from  a  shop  door 
and  ask  a  policeman  to  help  him.  Another  was  found  re- 
moving flowers   from   a   town    mansion   and  when   arrested 


204  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

cooll}'  remarked  that  they  had  been  presented  to  him.  A 
third — a  poor  man — kept  a  cabman  driving  about  with  him 
all  day,  and  at  last,  when  the  latter's  suspicions  were  aroused, 
he  found  his  fare  had  nothing  to  pay.  Such  a  man  is  perfectly 
cool  and  unconcerned  when  caught  red-handed,  always  ready 
with  some  excuse,  and  he  will  appropriate  without  discrimi- 
nation things  useful  or  worthless,  and  give  them  to  the  first 
man  he  meets.  He  steals  freel}^  but  bestows  generously. 
Sometimes  it  is  not  theft,  but  some  petty  assault,  that  first 
brings  him  under  the  notice  of  the  authorities,  and  then 
perhaps  he  is  found  to  be  insane.  He  has  no  sense  of  moral 
responsibility,  and  is  blind  to  the  starvation  of  his  wife  and 
family,  while  he  revels  in  delusions  of  his  wealth,  grandeur, 
and  omnipotence.  His  moral  depravity  shows  itself  in 
sexual  talk  and  impulses.  One  man  disowns  his  wife ;  says 
the  children  may  be  his,  but  that  he  only  lived  with  the 
woman,  and  that  he  is  going  to  marry  the  beauty  of  the 
season  to-morrow.  He  has  no  sense  of  propriety,  and  in 
the  presence  of  the  female  sex  his  erotic  passion  is  apt  to 
show  itself.  There  is  no  doubt  that  in  such  cases  there  is 
an  insane  exaltation  of  the  sexual  instinct.  Even  when 
erection  is  impossible,  the  excitement  of  this  passion  is  some- 
times remarkably  strong,  and  still  it  is  a  curious  fact  in  the 
history  of  such  cases  that  their  sexual  insanity,  of  which 
they  seem  so  unconscious,  does  not  prevent  the  vilest  accu- 
sations being  made  by  them  against  others.  They  frequently 
have  the  delusion  that  their  wives  are  unfaithful,  but  they 
see  not  the  mote  in  their  own  eye,  see  no  harm  in  proposing 
marriage  to  a  dozen  women  in  one  day. 

In  the  sphere  of  the  intellect  we  find  considerable  and 
disorderly  excitement ;  the  attention  is  wayward,  all  the  more 
so  because  of  the  intense  egotism  of  the  man.  He  is  too  much 
occupied  with  himself,  his  great  ideas  and  schemes  and  his 
extravagant  conceptions  to  listen  quietly  to  what  is  said  to 
him.  His  delusions  var}-  every  hour.  You  cannot  suggest 
anything  to  him  that  he  does  not  possess  or  that  he  cannot 
accomplish.  With  him,  to  wish  a  thing  is  to  have  it,  and 
all  things  are  possible  to  him.  At  one  and  the  same  time  he 
is  the  crucified  Saviour,  the  Holy  Ghost,  and  the  Heavenly 


GENERAL  PARALYSIS  OF  THE  INSANE  205 

Lord ;  all  that  he  wants  is  merely  to  sign  his  name  and 
earth  and  heaven  will  pass  away.  If  you  should  mildly 
suggest  that  you  can  overpower  him,  he  will  lie  to  you  and 
unblushingly  swear  that  he  killed  ten  men  last  night.  His 
wealth  is  unbounded.  One  poor  carter  entertained  the 
delusion  that  he  had  leased  a  large  farm,  and  was  going  to 
America  to  buy  horses  for  it.  Another  declared  that  the 
asylum  is  heaven,  and  after  two  days'  residence  told  us  that  he 
had  been  round  the  world  since  he  came.  If  we  could  imagine 
all  the  extravagant  day-dreams  of  the  people  of  this  world 
garnered  together,  we  might  form  some  conception  of  the 
endless  variety  of  grandiose  delusions  which  possess  the 
mind  of  the  general  paralytic. 

The  excitement  may  show  itself  in  the  form  of  maniacal 
violence.  One  large,  powerful  fellow,  for  example,  was  in  a 
state  of  intense  religious  exaltation  when  admitted.  He  was 
in  a  perfect  fury  of  excitement,  talked  very  loud,  and  kept 
up  this  mental  pace  with  such  a  torrent  of  language  that  to 
get  a  word  in  edgeways  was  simply  impossible.  He  was 
quite  absorbed  with  his  own  religious  egotism,  very  masterful, 
irritable,  and  difficult  to  regulate.  He  was  secluded  because 
of  his  violence,  and  his  sudden  impulsive  attacks,  for  several 
days.  Violence  may  take  the  form  of  destructiveness,  often 
because  of  delusions.  A  man  who  believes  himself  a 
millionaire  regards  with  disgust  his  homely  furniture  and 
effects,  once  his  household  gods,  and  may  proceed  far  in  his 
work  of  destruction  before  he  is  interfered  with.  But 
although  we  have  this  violence  and  excitement,  the  difficulty 
of  control  is  more  apparent  than  real,  "because  there  is 
usually  a  facile  disposition  that  can  be  played  with  if  only 
you  humour  your  patient,  a  childishness,  a  superficial  nature 
that  makes  the  general  paralytic  usually  very  manageable 
even  in  the  midst  of  his  passion,  if  taken  the  right  way. 
You  can  lead  him  as  a  little  child,  but  you  cannot  drive 
him.  Though  facile  as  children,  they  are,  like  children, 
irritable,  impulsive,  impetuous,  and  self-willed.  A  study 
of  the  mental  character  of  these  patients  gives  you  a  replica 
of  childhood  which  no  other  form  of  insanity  can  compare 
with.     The    memory  for    recent    events,   and    gradually   for 


2o6  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

older,  is  impaired.  Because  of  his  now  treacherous  memory, 
the  patient  fails  in  keeping  promises,  and  fails  also  even  if  he 
should  remember  them,  because  his  moral  sense  is  gone.  His 
ideas  are  mere  childish  aspirations.  Like  the  child,  he  has 
large  ideas  ;  but  with  the  child  they  are  to  be  realized  in 
foUure,  with  him  they  are  realized  now.  I  have  often  puzzled 
over  the  question,  Does  the  general  paralytic  really  believe 
all  he  says,  or  is  he  consciously  boastful  and  untruthful  from 
lack  of  moral  sense  ?  The  evidence  of  mental  dissolution  is 
seen  in  the  inability  to  perform  any  task  properly — no  matter 
how  simple.  This  is  due  to  want  of  memory  and  want  of 
attention,  to  mental  unrest,  and  a  state  of  mental  confusion. 

The  moral  defects  have  been  partially  dwelt  upon,  but  the 
whole  moral  character  becomes  gradually  effaced,  and  the 
condition  of  early  childhood  is  apparent  in  utter  selfishness, 
indifference  to  the  wants  of  others,  and  inability  to  recognise 
any  moral  significance  in  anything.  One  of  our  patients,  a 
man  of  sixty,  was  admitted  as  a  criminal  case.  He  passed 
a  profligate  woman  in  a  public  park,  and  with  a  weapon  in 
his  hand  killed  her  on  a  sudden  impulse.  When  questioned 
about  it,  some  weeks  after,  he  replied  with  a  smile  of  self- 
complacency,  '  Yes  ;  I  killed  three  hundred  of  them.'  The 
manners  and  habits  are  altered ;  untidiness  in  personal 
appearance  indoors,  outdoors,  at  table,  everywhere  ;  but  to 
this  there  are  exceptions  ;  indeed,  a  few  retain  for  a  long 
time  their  sense  of  cleanliness  and  order. 

Rather  too  much  has  been  made  of  the  affections  of  the 
special  senses  in  this  disease.  It  is  alleged  that  loss  of  the 
sense  of  smell  is  not  uncommon,  that,  as  already  mentioned, 
sight  affection  is  frequent,  that  colour-blindness  is  often 
observed,  and  that  deafness  has  been  noticed  as  an  early 
symptom  in  some  cases.  It  is  important  to  give  a  caution 
here,  and  to  remember  always  that  symptoms  or  physical 
signs  observed  in  the  history  of  the  disease  may  be  no  more 
an  integral  part  of  it  than  housemaid's  knee  is  of  pneumonia, 
though  they  may  appear  synchronously  in  the  same  patient. 
Remember  also  that  the  fact  that  a  man  has  little  or  no 
sense  of  smell  is  no  proof  that  he  could  ever  smell  well,  and 
a  man  may  be  colour-blind  for  want  of  education.     I  have 


GENERAL  PARALYSIS  OF  THE  INSANE  207 


tested  many  patients  with  the  colour  test,  and  found  them — 
excepting  the  really  demented  cases,  of  course — as  capable  as 
the  average  sane  individual. 

But  you  will  find  hallucinations  of  the  senses  prevalent. 
Thus,  one  patient  declared  that  he  had  seen  in  the  night  his 
house  filled  with  black  dogs,  and  the  noise  of  their  howling 
kept  him  awake  all  night.  He  had  the  hallucination  also 
that  a  drowned  man  was  touching  him,  said  that  his  saliva 
tasted  very  bitter  and  that  it  was  poisoned,  that  laudanum  had 
been  given  him,  and  the  doctor  had  opened  him  in  his  sleep, 
and  that  he  had  been  blistered  with  two  fly-blisters.  He  was 
subject  also  to  various  other  sense  perversions  and  hallucina- 
tions. It  must,  however,  be  observed,  by  way  of  correction, 
that  many  so-called  hallucinations  of  the  general  paralytic  are 
lies  or  fanciful  delusions,  and  though  I  have  given  the  above 
long  catalogue  all  from  the  mouth  of  one  man,  a  second 
revision  of  his  case  might  take  some  of  his  statements  out  of 
the  category  of  hallucinations  or  delusions. 

Eight  Mental  Varieties  of  General  Paralysis 
(Mickle). 

Mickle  recognises  eight  mental  varieties  in  the  first  stage. 
These  are  :  (i)  Symptoms  of  dementia  predominant,  in  which  are 
found  all  grades  of  mental  failure  and  deficiency.  (2)  Ex- 
pansive delirium  predominant.  Here  grandiose  ideas  and  a 
feeling  of  elation  or  quiet  self-satisfaction  are  manifested. 
(3)  Mental  excitement  predominant,  with  probably,  though  not 
necessarily,  exaltation  and  grandiose  ideas.  There  may  be 
excitement,  mental  and  motor,  or  merely  silent  resistiveness 
and  destructiveness,  or  what  is  described  as  the  galloping  form 
of  general  paralysis — raving,  violent,  sleepless,  with  typhoid- 
like symptoms  {vide  'Acute  Delirious  Mania').  (4)  Hypochon- 
driac symptoms  prominent.  In  such  cases  the  essential  mental 
state  may  be  hypochondria,  with  delusions  as  to  the  viscera, 
and  especially  regarding  the  liver  and  bowels.  According 
to  Mickle,  this  form  is  next  in  frequence  to  the  expansive;' 
but  in  my  experience  the  first  class,  the  early  demented,  are 
more  prevalent  than  the  hypochondriacal.  (^)  Melancholic 
symptoms  prominent.  (6)  Persecutory  delusions  prominent.  (7) 
Stuporose  form.     (8)  Circular  form. 


2o8  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

Physical  Signs  of  General  Paralysis. 

What  reall}-  constitute  the  chief  grounds  of  our  diagnosis 
have  yet  to  be  determined  with  a  fuller  consensus  of  agree- 
ment than  at  present  obtains.  Much  that  is  illogical  has 
been  ^vritten  on  the  subject,  and  many  signs  have  been 
adduced  as  evidence  without  due  weight  being  given  to  the 
personal  equation  or  a  recognition  of  the  truth  that  the  ideal 
man  is  not  the  normal  man.  General  paralysis  in  one  instance 
on  record — and,  of  course,  there  may  be  many  more — was 
strongly  suspected  in  the  case  of  a  man  whose  speech  was 
affected,  whose  tongue  was  tremulous,  but  who  recovered, 
and  was  able  to  assure  his  physician  that  the  speech  affection 
and  the  tremulous  tongue  had  lasted  him  all  his  life.  In  the 
same  way  much  is  made  of  the  state  of  the  pupil ;  but  careful 
observers  of  their  patients  in  general  practice  will  frequentl}^ 
notice  inequalities  of  the  pupils,  which  come  and  go,  or  which 
mav  continue  for  long  periods,  if  not  permanently,  and  yet 
have  no  connection  with  general  paratysis  at  all.  This  is 
particularly  seen  in  cases  of  nervous  exhaustion,  where  there 
is  no  question  of  insanity  at  all.  While  not  neglecting  to 
observe  all  the  nervous  phenomena  present  in  our  patients 
when  thev  first  come  under  notice,  and  while  they  are  under 
treatment,  we  must  be  careful  to  remember  that  there  is  a 
past  history,  good  or  bad,  and  in  the  light  of  that  our  diagnosis 
must  be  made. 

Attention  may  first  be  directed  to  the  state  of  the  pupils, 
the  appearance  and  reactions  of  which  are  regarded  as  of 
great  importance.  Recent  researches,  together  with  the 
observations  of  Bevan  Lewis  (British  Medical  Journal,  i8g6), 
have  enlarged  our  conception  of  the  multiform  connections 
of  the  pupillary  reflex  mechanism,  so  that  at  present  the 
clinical  value  of  the  pupillary  reactions  must  be  carefulty 
reconsidered.  It  is  impossible  here  to  discuss  anatomical 
relations  and  purely  physiological  questions;  but  the  follow- 
ing observations  require  to  be  made  regarding  the  pupil : 
first,  the  size  ;  second,  inequalities  ;  third,  alterations  in  form  ; 
fourth,  reactions. 

The  size  of  the  pupil  is  alone  of  no  importance,  but  ver}- 


GENERAL  PARALYSIS  OF  THE  INSANE  209 

small  pupils  may  suggest  organic  disease  when  they  fail  to 
react  to  light  and  other  stimuli.  Inequality  is  regarded  as  of 
more  significance,  but  it  must  be  remembered  that  inequalities 
may  be  temporary  and  indicative  really  of  functional  irregu- 
larity. This  is  seen  in  nervous  people,  in  cases  of  nervous 
exhaustion  often  in  the  morning,  and  indicates  defective 
co-ordination  of  temporary  character.  The  form  of  the 
pupil  is  more  important,  but  here  also  careful  inquiry  should 
be  made  into  the  history  of  the  case,  for  alteration  in  form 
may  be  due  to  iritis  or  degenerative  changes  in  the  iris. 
The  form  may  be  oval,  square,  or  irregular,  and  it  is  usually 
found  that  one  pupil  is  more  affected  than  the  other. 

The  reactions  give  very  important  information.  Let  us 
first  consider  reflex  dilatation  (Erb's).  The  pupils  dilate 
normally  in  response  to  various  sensory  stimuli,  cutaneous, 
muscular,  auditory,  electrical ;  but  according  to  Bevan  Lewis, 
this  reaction  fails  in  general  paralytics  to  the  extent  of  nearly 
45  per  cent,  in  the  male.  In  a  series  of  examinations  made 
in  my  clinique  and  in  the  wards  afterwards  the  percentage 
was  not  found  to  be  so  large,  and  the  value  of  this  symptom 
is  rather  discounted  by  the  fact  that  it  is  not  peculiar  to 
general  paralysis,  and  that  Lewis  has  found  it  in  24  per 
cent,  of  epileptics.  This  defect  of  reflex  dilatation  is  not 
the  same  in  both  eyes  as  a  rule.  It  may  even  be  unilateral. 
Contraction  in  response  to  light  is  often  impaired,  and  this 
may  be  associated  with  loss  of  reflex  dilatation.  The  Argyll- 
Robertson  pupil  (loss  of  light  reflex  with  contraction  on 
accommodation  persisting)  is  especially  seen  in  spinal  forms 
of  general  paralysis.  Consensual  convergence  of  the  eyes 
for  accommodation  is  sometimes  defective,  the  one  eye  con- 
verging steadily,  the  other  not,  or  coming  to  a  stand-stih 
half  way,  and  then  diverging. 

The  facial  features  have  for  a  long  time  attracted  consider- 
able attention.  Tremors  may  be  observed  affecting  any  or 
all  of  the  muscles.  These  tremors  may  be  of  the  very  finest 
character,  becoming  coarser  and  more  generally  distributed 
with  excitement,  or  when  a  strain  is  put  on  the  muscles,  as 
when  opening  the  mouth  wide,  or  putting  out  the  tongue. 
These   tremors   are   not   peculiar  to   this   disease  ;   they  are 

14 


2IO  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

often  seen  during  emotional  outbursts  or  when  the  nervous 
state  of  the  individual  is  below  par.  If  the  tremors  persist, 
affecting  the  muscles  more  deeply,  and  inducing  more  or  less 
facial  distortion,  without  any  other  explainable  cause,  and  if 
the  lip-muscles,  the  buccal  and  zygomatic,  are  more  or  less 
involved,  together  with  those  surrounding  the  mouth,  this 
symptom  acquires  grave  importance.  It  will  probably  be 
observed  that  the  patient  has  lost  co-ordinating  power,  as 
when  he  attempts  to  whistle,  to  smile  pr  speak,  and  in  more 
advanced  cases  there  may  frequently  be  convulsive  move- 
ments when  a  voluntary  effort  to  speak,  smile,  or  whistle  is 
made. 

The  tongue  is  usually  tremulous,  often  jerky  or  convulsive, 
and  protrusion  may  be  difficult  and  in  advanced  cases  im- 
possible. The  speech  is  regarded  as  a  very  distinctive 
feature.  At  first  there  is  often  difficulty  with  long  words, 
especially  where  there  is  redundancy  of  consonants,  notably 
L  and  R.  At  first  the  mental  facult}^  of  speech  may  be 
apparently  normal,  the  difficulty  being  one  merely  of  articu- 
lation ;  but  as  mental  weakness  proceeds  the  defect  of  speech 
is  one  of  retardation  with  stops  and  hesitation,  as  well  as 
impaired  articulation.  Such  combinations  as  '  Parliamentary 
Road,'  '  Royal  Infirmary,"  may  be  employed  to  test  the 
speech  where  there  is  a  suspicion  of  general  paralysis  ;  but 
inquiry  should  always  be  made  regarding  the  speech  function 
in  health,  for  not  everyone  can  rattle  off  a  patter-song  or 
speak  quickly  without  tripping. 

The  finer  muscular  movements  and  combinations  are  the 
first  to  suffer,  and  this  is  well  seen,  not  only  in  the  face, 
but  in  a  change  of  handwriting.  It  becomes  tremulous, 
jerky,  irregular,  and  blotted  ;  but  by  this  time  the  diagnosis 
of  the  disease  may  already  have  been  safely  made.  The 
mental  dissolution  is  evident  in  the  missing  of  letters  or 
syllables,  in  repetitions  and  confusion  of  ideas. 

The  larger  muscular  movements  are  evidentl}-  intact  for 
some  time  during  the  progress  of  the  disease.  Locomotion 
may  be  unimpaired,  the  gait  and  stride  being  free  and 
swinging  as  of  old  ;  but  the  dynamometer  soon  reveals  a 
weakness  of  grip,  and  in  turning  sharply  there  may  be  seen 


GENERAL  PARALYSIS  OF  THE  INSANE  211 

a  slight  swaying  or  staggering  movement.  If  the  spinal 
form  is  manifested  the  paralytic  gait  is  an  early  symptom, 
and  may  be  spastic  or  tabic.  As  the  disease  proceeds,  no 
matter  what  form  it  takes,  progressive  paralysis  in  one  direc- 
tion or  other  becomes  more  and  more  evident. 

The  reflexes  may  be  altered  or  wanting.  The  feet  show 
loss  or  diminution  of  reflex  action,  and  finally  it  is  limited 
to  the  toes.  The  knee  reflex  may  be  lost  or  exaggerated. 
Ankle  clonus  is  rarely  manifested.  Of  the  cremasteric  and 
abdominal  reflexes  nothing  definite  can  be  said.  The  knee 
and  ankle  reflexes  differ  in  spastic  and  tabic  cases  as  might  be 
expected,  for  they  correspond  negatively  or  positively  with 
the  description  given  in  text-books  for  these  two  varieties  of 
spinal  disease. 

It  is  difficult  to  test  sensation  in  some  cases,  and  the  sense 
of  touch  can  only  be  measured  approximately.  Cutaneous 
sensation  is  not  impaired  at  first,  though  certainly  it  is  as 
the  disease  proceeds ;  the  muscular  and  temperature  senses 
are  not  impaired  till  the  latest  stages  of  the  disease.  Of 
course,  the  advancing  dementia  must  give  negative  results 
eventually. 

These  alterations  and  diminutions  of  nervous  function 
indicate  how  widely  the  disease  spreads  when  once  its  onset 
is  fully  manifest ;  but  there  is  no  similarity  in  the  manner  of 
onset,  in  the  selection  of  a  particular  nervous  plexus  for  first 
attack,  or  in  the  order  of  progression  of  the  disease. 

The  Second  Stage. — The  duration  of  the  first  stage  is 
variable;  it  may  last  for  a  year  or  more;  it  may  be  rapidly 
expended,  and  the  patient  pass  into  the  second  stage  in 
three  months.  Nor  is  there  any  sharp  dividing  line  between 
the  two.  The  excitement  becomes  less  acute  ;  the  patient 
sleeps  more,  puts  on  fat,  becomes  heavy  and  flabb},,  and  in 
some  cases  may  appear  to  be  actually  recovering,  for  he 
settles  down  to  occupation,  makes  himself  useful  in  the 
ward,  exercises  a  supervision  over  other  patients  which 
would  appear  to  indicate  a  restoration  to  his  former  health 
and  usefulness,  but  for  the  fact  that  this  activity  and  super- 
vision and  helpfulness  is  rather  fussy  and  officious.  There 
may  be   spurts  of  excitement,   but  they  are  not  sustained, 

14 — 2 


212  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

Often  we  observe  long  spells  of  stupor,  or  at  least  of  mental 
dulness  and  physical  inertia,  with  occasional  interludes  of 
excitement  and  exaltation  which  by -and -by  diminish  to 
vanishing  point.  A  careful  examination  of  the  patient's 
mental  condition  will  reveal  the  havoc  that  has  been  made 
in  the  sphere  of  the  whole  mental  constitution.  The  memory 
is  more  and  more  impaired  ;  if  the  patient  sees  a  friend, 
perhaps  walks  with  him  for  half  an  hour,  he  forgets  all 
about  it,  or  at  least  much  that  has  occurred  two  hours  after. 
His  faculty  of  observation  is  diminished ;  the  moral  nature 
is  more  and  more  affected.  He  loses  all  sense  of  moral  rela- 
tions, and  he  becomes  emotional  like  a  child. 

The  changes  in  the  nervous  system  are  now  very  evident ; 
the  motor  system  is  being  undermined  ;  locomotion  is  more 
difficult ;  the  arms  and  hands  are  feebler,  and  the  finer 
movements  show  marked  inco-ordination.  The  advancing 
paralysis  may  be  rapid,  or  it  may  be  slow ;  it  may  appear  to 
be  partial,  or  it  may  be  general ;  but  the  result  is  in  all  cases 
a  progressive  diminution  of  function,  an  advancing  paralysis. 
The  eye  symptoms  are  now  unmistakable,  and  sight  may  be 
affected  by  retinal  changes  or  atrophy  of  the  optic  nerve. 
The  facial  expression  changes  to  one  of  fatuity  ;  the  lines  of 
feature  are  more  and  more  brushed  out,  and  often  a  fat, 
puffy,  greasy,  expressionless  character  is  acquired.  The 
play  of  feature,  the  rippling  smile,  the  prompt  responsive- 
ness, the  bright  and  animated  expression  have  disappeared ; 
the  appetite  is  voracious  still,  but  the  sexual  appetite,  often 
exalted  in  the  first  stage,  is  now  usually  lost. 

The  Third  Stage. — There  is  here  little  mind  left,  the 
patient  is  very  emotional,  is  easily  made  to  laugh  and  cr}^, 
his  memory  is  quite  gone,  and  though  the  shadow  of  his 
former  happy  self  is  sometimes  manifest,  there  is  little  or  no 
excitement,  and  when  it  does  exist  it  is  of  an  indefinite, 
purposeless  character.  The  tbird  stage  is  the  bed-ridden 
stage,  for  the  patient  has  difficulty  in  walking,  he  may  be 
entirely  paraplegic,  he  needs  much  care  and  nursing,  and 
requires  to  be  fed  because  of  glosso-labio-pharyngeal  paralysis. 
The  sphincters  are  no  longer  controlled,  paralysis  has  ad- 
vanced here  also,  and  the  draw-sheet  is  continually  required 


GENERAL  PARALYSIS  OF  THE  INSANE  213 

because  of  his  wet  and  dirty  habits.  The  superfluous  fat  is 
disappearing,  and  bed-sores  from  trophic  paralysis,  though 
preventable  at  first,  are  certain  to  appear  within  a  few  weeks 
of  death. 

Differential  Diagnosis. 

It  should  not  be  difficult  when  once  the  disease  fully  shows 
itself  to  make  out  a  case  of  general  paralysis,  but  there  are 
within  its  own  borders  varieties  diverging  from  the  general 
type,  melancholic,  hypochondriacal,  demented,  spastic  and 
ataxic  cases,  and  there  are  beyond  its  own  borders,  but 
closely  merging  with  them,  groups  that  in  some  respects 
resemble  general  paralysis,  and  may  confuse  the  diagnosis. 
What  has  been  said  in  the  introduction  to  this  chapter  on 
pseudo  forms  of  general  paralysis  should  be  remembered 
here.  The  types  that  may  raise  doubts  are  cases  of  chronic 
alcoholism,  insanity  from  sunstroke  and  lead  poisoning, 
syphilitic  insanity,  acute  mania,  insanity  with  cerebral 
softening,  or  associated  with  limited  paralysis,  locomotor 
ataxia,  paralysis  agitans,  epilepsy,  and  apoplexy.  There  is 
no  occasion  to  go  into  the  differential  diagnosis  of  all  these 
types.  It  is  only  rarely  that  the  question  will  be  raised  with 
reference  to  some  of  them,  such  as  epilepsy  and  apoplexy, 
but  of  some  of  the  others  it  is  necessary  to  give  distinguish- 
ing features. 

Chronic  Alcoholic  Insanity. 

The  tremor  is  here  more  general ;  there  is  less  ataxia,  the 
delusions  are  seldom  of  the  exalted  type,  and  there  is  usually 
an  absence  of  the  facile  disposition  and  self-satisfaction 
which  are  so  characteristic  of  general  paralysis.  There  is 
an  absence  of  the  expansiveness  even  in  its  mildest  form, 
and  of  the  wayward  and  erratic  character  of  the  general 
paralytic.  A  careful  consideration  of  the  motor  symptoms 
will  reveal  a  more  progressive  character  and  a  more  extensive 
and  intense  implication  as  a  rule  in  the  general  paralytic. 
Further,  the  age  of  the  patient,  his  history,  and  the  mode  of 
onset  of  the  attack,  will  help  to  distinguish  the  one  from 
the  other  as  a  rule  without   much  difficulty.     Recognising, 


214  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

however,  that  alcoholic  excess  is  itself  a  potent  cause  of 
general  paralysis,  3^ou  may  find  in  the  latter,  especiall}'  where 
alcohol  is  the  chief  cause  of  the  disease,  a  nearer  approach 
to  the  symptoms  of  true  alcoholic  insanity. 

Syphilitic  Insanity. 

In  syphilitic  cases  the  nervous  symptoms  are  usuall}' 
earlier  in  their  appearance  than  the  mental,  and  are  not  so 
progressive.  There  are  noticeable  affections  of  the  cranial 
nerves,  ocular  troubles,  nocturnal  headache,  and  early  appear- 
ance of  convulsions.  The  symptoms  are  also  frequently 
unilateral.  Ataxia  is  less  noticeable,  the  symptoms  being 
more  distinctly  paralytic  at  the  outset,  and  localized  more 
definite^  than  in  general  paralysis.  The  treatment  of  a 
suspected  syphilitic  case  with  anti-syphilitic  remedies  will 
in  some  cases  determine  the  diagnosis,  but  not  always. 
There  are  cases  which  in  spite  of  the  rules  here  laid  down 
will  give  great  trouble  in  diagnosis. 

Insanity  with  Cerebral  Softening  or  Paralytic  Affections. 

There  are  cases  of  brain  softening  and  brain  atrophy  which 
I  have  noticed  more  particularly  in  women,  with  delirium, 
often  melancholic,  and  various  forms  of  paralysis,  e.g.,  of 
sight,  a  delirium  really  of  progressive  softening  and  atrophy 
of  the  brain  running  a  short  and  fatal  course,  and  to  be 
distinguished  from  general  paralysis  by  a  more  sudden  onset 
and  by  the  absence  of  m.ental  symptoms  that  could  possibly 
correspond  with  the  disease.  The  term  '  paralytic  dementia  ' 
is  one  frequently  applied  to  general  paralysis  in  its  final 
stages,  but,  properly  speaking,  it  should  be  reserved  for  those 
cases  associated  with  hemiplegia,  monoplegia,  and  other 
defined  and  limited  paralyses.  The  mental  symptoms  are 
usually  those  of  mild  dementia  with  occasional  attacks  of 
excitement  and  sometimes  exaltation  ;  the  paralysis  remains 
the  same  without  extension,  often  for  years. 

Acute  Mania. 

From  what  has  already  been  said,  it  will  be  evident  that 
we  must  frequently  be  called  upon  to  differentiate  between 


GENERAL  PARALYSIS  OF  THE  INSANE  215 

acute  mania  and  general  paralysis.  When  the  motor 
symptoms  are  slow  in  making  their  appearance,  it  is  often 
difficult  to  distinguish  between  the  two.  General  paralysis 
has  by  no  means  a  monopoly  of  exaltation  and  grandiose 
delusions,  for  they  often  occur  in  acute  mania  as  well  as  in 
other  forms  of  insanity.  The  diagnosis  should  be  delayed  if 
the  temperature  is  much  above  normal  with  no  bodily  con- 
dition to  account  for  it,  if  the  excitement  persists  for  a 
long  time,  and  if  there  is  even  the  faintest  suspicion  of 
tremor,  disordered  articulation,  or  pupillary  defect. 

Congestive,  Epileptiform  and  Paralytic  Seizures.    . 

Congestive  or  apoplectiform  attacks,  as  they  are  called  by 
some,  are  peculiarly  characteristic  of  geneiral  paralysis  in  its 
second  and  third  stages ;  but  they  may  even  appear  to  usher 
in  the  disease,  and  I  have  known  such  a  case  received  into 
one  asylum  apparently  in  the  lirst  stage  after  having  been 
discharged  from  another  asylum  on  recovery  from  a  con- 
dition of  stupor  the  sequel  to  a  congestive  attack.  These 
attacks  come  on  suddenly,  and  are  of  the  nature  of  apoplectic 
attacks  so  far  as  clinical  features  show  ;  but  the  pathological 
condition  is  not  a  haemorrhagic  apoplexy,  but  an  intense 
cerebral  congestion,  with  perhaps  resultant  haemorrhages  of 
lesser  gravity.  In  the  congestive  attack  you  have  the 
symptoms  of  apoplexy,  with  or  without  paralysis.  They 
may  occur  several  times  in  the  course  of  the  disease,  and 
not  infrequently  carry  the  patient  off  at  last.  The  epilepti- 
form is  of  the  nature  of  a  congestive  attack,  with  convulsions 
superadded.  Hemiplegic  seizures,  usually  of  very  slight  and 
transient  character,  often  appear  in  the  course  of  the  disease, 
but  they  become  more  serious  in  its  later  stages. 

Prognosis. 

The  prognosis  is  bad.  It  is  bad  as  regards  the  question 
of  recovery,  the  question  of  life,  and  the  duration  of  life.  It 
may  be  that,  as  alleged,  some  cases  do  recover,  but  as  a  rule 
appearances  are  deceptive  and  only  remissions  occur.  The 
best  encouragement  we  have  at  present  is  in  the  fact  that  the 
galloping  form  is  becoming  rarer,  and  that  the  course  of  the 


2i6  CLINICAL  MANUAL  OF  MENTAL  DISEASES 


disease  is  not  so  rapid.  Not  so  long  ago  we  reckoned  the 
average  duration  at  eighteen  months  to  two  years,  and 
where  exceptional  cases  lived  on  for  four  or  iive  years,  we 
began  to  doubt  whether  they  were  cases  of  general  paralysis 
or  not.  At  present  under  treatment  we  have  patients  whose 
average  duration  is  two  years  and  ten  months,  and  only  a 
third  of  these  are  in  the  final  stage.  The  second  stage 
appears  to  be  prolonged. 

Treatment. 

It  is  not  often  that  we  have  opportunities  of  treating 
patients  before  the  disease  becomes  confirmed,  but  in  general 
practice  the  attack  may  be  averted  or  considerably  delayed. 
It  is  well  therefore  to  remember  what  are  the  causes  of 
general  paralysis,  so  that  they  may  be  removed  if  possible, 
and  what  are  the  early  symptoms,  so  that  they  may  be  taken 
as  a  warning  in  time.  The  avoidance  of  excitement,  of 
alcoholic  and  sexual  stimulation,  of  undue  anxiety  and 
emotional  disturbance,  and  of  mental  overwork,  should  be 
insisted  on.  Change  of  scene,  active  physical  recreation,  a 
regular  mode  of  life,  a  suitable  dietary,  and  attention  to  the 
bowels,  should  be  enjoined. 

In  the  treatment  of  general  paralysis,  when  once  the  onset 
is  confirmed,  all  that  can  be  done  is  merely  palliative.  If  the 
attack  assumes  the  acute  maniacal  form,  and  there  is  risk  of 
injury  to  the  patient,  seclusion  may  have  to  be  resorted  to. 
Dr.  Clouston  has  tried  continuous  doses  of  sulphonal  in 
hot  milk,  and  says  that  he  has  thus  been  able  to  carry  the 
patient  safely  through  the  first  stage  without  injury  to  him- 
self or  others.  The  best  treatment  in  the  acute  stage  is 
outdoor  labour,  and  the  safest  and  simplest  kind  of  work  is  a 
wheelbarrow.  In  any  case  let  him  be  out  in  the  open  air  as 
much  as  possible  every  day.  Give  the  motor  excitement  the 
freest  play  possible  ;  tire  him  out  if  you  possibly  can.  In 
some  cases  bleeding  may  be  indicated.  In  all  cases  attend 
particularly  to  the  bowels,  and  let  the  diet  be  simple  and 
digestible.  Sedative  drugs  are  of  very  little  use  in  general 
paralysis  ;  a  hypodermic  injection  of  hyoscine  in  emergencies 
is  sometimes  useful.     In  the  later  stages  great  care  should 


GENERAL  PARALYSIS  OF  THE  INSANE  217 

be  exercised  in  feeding  these  patients  so  that  choking  may 
be  prevented,  and  minced  or  chopped  food,  liquefied  as  much 
as  possible,  should  alone  be  given.  The  patient  requires  a 
great  deal  of  nursing  and  care  when  once  he  becomes  bed- 
ridden, and  he  should  be  moved  about  in  bed,  and  out  of 
bed,  for  a  few  hours  daily,  if  possible,  and  kept  perfectly 
clean  and  comfortable  in  order  to  prevent  bed-sores.  A  very 
good  plan  is  to  harden  the  skin  with  white  of  egg  and  spirit, 
or  with  a  strong  tannin  solution  such  as  may  be  obtained 
from  tanners  ;  but  in  the  end  bed-sores  are  sure  to  appear, 
and  they  are  then  best  treated  with  carbolic  oil  or  some  other 
antiseptic. 

Clinical  Illustrations. 

The  various  manifestations  of  general  paralysis,  though  not 
necessarily  in  the  order  here  given,  have  many  points  of 
illustration  in  the  two  immediately  following  cases,  the  first 
showing  two  forms,  melancholia  and  mania,  the  second  the 
tabic  form  of  general  paralysis. 

Alternating  Form  of  General  Paralysis. 
J.  B.,  a  country  labourer,  with  a  history  of  alcoholic 
excess  and  heredity.  On  admission  he  was  melancholy, 
not  inclined  to  conversation,  and  slow  to  answer  questions. 
He  was  under  the  delusion  that  no  one  would  employ  him, 
and  he  was  so  utterly  miserable  that  he  secluded  himself 
from  the  sight  of  everyone,  and  would  not  go  out  of  doors. 
He  had  an  unspeakable  dread  that  something  was  going 
to  happen  to  himself  and  family,  and  he  refused  food.  One 
significant  symptom  attracted  attention  ;  his  pulse  was  120, 
and  there  were  no  physical  complications  to  account  for  it. 
There  were  no  nervous  phenomena  of  any  account ;  the 
pupils  were  natural  in  size  and  outline,  but  sluggish  ;  the 
tongue  was  protruded  a  little  to  the  right  side,  and  his 
general  condition  was  that  of  pallor,  want  of  muscular  tone, 
and  anaemia.  A  fact  which  struck  us  as  very  curious,  how- 
ever, was  that  his  despondency,  contrary  to  the  usual  rule  in 
melancholies,  came  on  towards  evening  and  had  disappeared 
by  morning.  He  did  not  sleep  well,  was  wakeful,  fidgety, 
restless,  and  would  not  keep  in  bed. 


2i8  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

He  was  sent  to  work  in  the  garden,  became  more  cheerful, 
less  restless,  and  appeared  convalescent  ;  but  a  fortnight 
later  he  was  reported  as  nervous  and  frightened  and  attempt- 
ing to  get  out  of  one  of  the  dormitory  windows  at  night. 
Nervous  twitchings  were  now  observed  round  the  eyelids 
and  mouth  ;  the  voice,  at  first  regarded  as  of  melancholic  tone, 
was  now  distinctly  emotional  and  tremulous ;  he  was  facile, 
easily  diverted  from  one  subject  to  another,  but  peculiarly 
sensitive  in  his  feelings.  Later  on  the  depression  had  dis- 
appeared ;  he  showed  temper  and  impatience  when  his  wife 
did  not  visit  him  as  expected.  He  was  next  reported  as 
gaining  strength  and  steadily  improving  in  his  mental  con- 
dition, but  the  twitchings  about  the  eyes  and  mouth  were 
still  present ;  he  was  discharged  much  improved,  and  was 
again  admitted  in  three  months. 

Report  on  Second  Attack. — He  is  now  decidedly  paretic  ;  he 
soon  gets  tired  walking,  and  staggers  and  reels  like  a  drunken 
man  ;  his  words  are  interrupted,  a  peculiar  quivering  move- 
ment is  visible  in  the  under-lip,  even  when  the  mouth  is  closed. 
There  is  still  nothing  noteworthy  in  the  pupils,  except  that 
they  are  dilated,  and  remained  so  for  two  or  three  months  with 
no  inequality  or  irregularity.  He  now  proves  a  most  trouble- 
some case,  violent,  abusive,  requiring  restraint,  masturbating 
without  shame,  making  himself  very  officious  in  the  wards, 
choking  up  the  water-closets  with  coals  under  the  idea  that 
he  is  carrying  out  some  benevolent  scheme.  He  has 
delusions  of  exalted  character  :  that  he  is  to  inherit  great 
wealth,  that  a  legacy  has  been  left  him.  Under  the  influ- 
ence of  these  grandiose  delusions  he  was  found  destroying 
his  furniture  or  proposing  to  give  it  away  so  as  to  make  room 
for  the  magnificent  furniture  which  his  new  wealth  would 
buy.  The  sexual  element  at  this  stage  was  a  very  strong 
feature  of  his  case.  He  became  most  violent  and  dangerous, 
making  vindictive  attacks  on  the  attendants  with  any 
weapons  he  could  lay  hands  on,  smashing  doors  and  windows 
in  order  to  get  to  his  wife,  whom  he  believed  to  be  just  out- 
side. 


Plate  IV.— GENERAL  PARALYSIS.      PARALYTIC  INSANITY. 


GENERAL    I'ARALYrilS    (HOMICIDAL 


I'AKALYilC    I.NSANITY. 


GENERAL    PARALYSIS    (SURGICAL    SHOCK.) 


GENERAL    PARALYSIS. 
To  face  p.  21S. 


GENERAL    PARAIA\SIS. 


GENERAL  PARALYSIS  OF  THE  INSANE  219 

Case  of  Tabes  Dorsalis  with  General  Paralysis. 

C.  B.,  set.  39,  married,  soldier;  father  was  insane  for  three 
months.  History  of  prese}it  attack:  Unsettled,  and  could  not 
fix  attention  on  his  work  ;  did  stupid  things  in  the  house  ; 
although  his  wife  and  children  were  starving,  he  spent  what 
money  he  had  in  useless  articles,  and  gave  large  orders  for 
things  for  which  he  could  not  pay.  On  admission  he  imagined 
he  was  possessed  of  great  wealth,  was  restless,  talkative, 
and  excited  ;  could  not  sleep  at  nights  owing  to  imaginary 
insects  annoying  him  (hallucmation  of  touch)  ;  the  left  pupil 
was  considerably  larger  than  the  right,  both  reacting  to 
light ;  the  tongue  was  tremulous,  sensation  appeared  normal, 
the  reflexes  were  not  impaired,  and  the  special  senses  were 
apparently  healthy. 

Progress  of  Case. —  '  The  exaltation  is  well  marked  ;  patient 
thinks  he  is  a  very  fine  fellow  ;  says  he  is  a  magnificent  writer, 
while  in  reality  it  is  all  he  can  do  to  write  his  name  legibly ; 
there  is  considerable  mental  enfeeblement.  The  articulation 
is  correct,  the  tongue  tremulous  ;  the  left  pupil  varies  in 
size,  being  sometimes  larger  and  sometimes  smaller  than  the 
right ;  the  outline  is  sometimes  irregular,  but  not  always. 
There  are  also  tabic  symptoms.  When  made  to  stand  with 
his  feet  together  and  his  eyes  shut,  he  sways  about  and  tends 
to  fall.'  At  a  later  stage,  a  year  after  admission,  he  is  de- 
scribed as  follows  :  '  A  mild  exaltation  which  shows  itself  more 
in  a  self-satisfied,  contented  expression  than  in  any  well- 
marked  delusion.  He  states  that  he  has  £4,000,  but  more 
mechanically  than  otherwise  ;  and  in  the  same  breath  he 
talks  of  his  being  a  corporal  in  the  army  with  a  pension  of 
thirteen  pence  a  day.  There  is  neither  excitement  nor  de- 
pression. Enfeeblement  is  well  marked  ;  it  is  seen  in  the 
facile  disposition,  in  his  being  too  easily  controlled,  in  the 
want  of  self-assertion,  and  the  absence  of  mental  vigour. 
The  memory  is  impaired,  he  does  not  recollect  names  of 
places  well ;  he  can  answer  questions,  is  quite  coherent,  and 
his  attention  does  not  waver  much  in  simple  conversation. 

'  The  symptoms  of  locomotor  ataxia  are  well  marked.  Even 
with  his  eyes  open  he  has  great  difficulty  in  walking,  and 


220  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

cannot  stand  unsupported  ;  his  lower  limbs  are  little  better 
than  artificial  limbs ;  co-ordination  of  arms  and  hands  is  not 
impaired.  In  the  train  one  day,  when  at  a  speed  of  thirty 
miles  an  hour,  he  threaded  a  needle  and  stitched  a  small 
button  on  his  trousers.  This  speaks  well  also  for  his  eye- 
sight, co-ordination  and  nerve.  Sensation  to  pain  and  touch 
much  impaired  in  lower  extremities,  much  less  so  in  upper. 
Plantar  reflex  impaired,  tendon  reflex  abolished.  Right  pupil 
larger  than  left,  but  both  of  medium  size  ;  they  contract  to 
accommodation,  but  not  to  light.' 

General  Paralysis  with  Early  Dementia. 

The  following  case  illustrates  the  type  of  general  paralysis 
characterized  by  mental  enfeeblement  and  the  absence  of 
marked  exaltation  even  at  the  beginning  of  the  disease. 

W.  B,,  £et.  32  ;  father  has  had  apoplexy ;  the  patient  was 
seized  with  left  hemiplegia,  of  which  a  faint  trace  still 
remains,  especially  in  the  left  leg.  His  personal  history  is 
fairly  good  ;  the  attack  of  hemiplegia  came  on  when  he  was  at 
work  in  a  coal-pit,  but  he  was  able  to  walk  home,  though  his 
leg  was  somewhat  stiff.  His  speech  became  affected,  being 
slow  and  thick.  He  became  weak  and  childish,  but  a 
mental  change  in  this  direction  was  noticed  before  the  onset 
of  the  hemiplegia  ;  the  pupils  at  an  early  stage  were  unequal 
and  the  reactions  impaired ;  there  is  slight  facial  deficiency, 
considerable  tremor  of  the  tongue,  and  slight  tremor  of  the 
lips ;  he  also  exhibits  other  nervous  symptoms  of  general 
paralysis.  This  is  a  very  slow  case,  and  while  there  is  a 
childish  contentment,  there  is  no  real  exaltation. 

Female  Case  of  General  Paralysis  with  Syphilitic  History. 

The  report  of  the  following  female  case  of  general  paralysis 
has  several  points  of  interest, 

I.  M.,  set.  32,  insane  two  weeks,  died  in  one  year  from 
that  time.  She  had  several  miscarriages,  and  the  children 
living,  as  well  as  the  patient,  had  shown  signs  of  syphilitic 
affection.  The  husband's  history  confirms  this  conclusion. 
She  passed  through  a  brief  period  of  melancholic  excitement 


GENERAL  PARALYSIS  OF  THE  INSANE  221 

during  lactation  ;  she  threatened  to  poison  herself,  or  throw 
herself  out  of  the  window,  and  had  threatened  her  children's 
lives  ;  she  had  a  strong  animus  to  her  husband,  and  enter- 
tained delusions  regarding  his  relations  with  the  nurses. 
In  a  very  few  weeks  she  became  quite  demented,  but  in  a 
feverish  state  of  restlessness,  with  destructiveness,  tearing  to 
pieces  clothing,  bed-coverings,  etc.  Her  speech  became 
entirely  paralyzed,  the  pupils  were  unequal,  and  did  not 
respond  readily  to  light.  In  the  eighth  month  of  her 
disease  she  had  an  attack  of  hemiplegia.  She  then  became 
bedridden,  and  at  the  last  sank  rapidly  and  died.  On  post- 
mortem examination,  the  characteristic  morbid  appearances 
were  found  in  the  brain,  and  also  left  lobar  pneumonia, 
though  no  clinical  symptoms,  not  even  a  rise  of  temperature, 
occurred  during  life. 

Case  beginning  with  a  Congestive  Attack. 

Robert  M.,  set.  34,  stupid,  mentally  clouded,  but  had 
hallucinations  of  hearing.  Said  he  heard  people  telling  him 
to  do  things.  Tongue  tremulous.  Left  pupil  larger  than 
right.  Plantar  and  knee  reflexes  exaggerated.  Mentally 
cleared  up,  and  was  discharged,  but  a  few  months  later  was 
sent  back  to  the  asylum  with  marked  motor  symptoms  of 
rapidly-advancing  general  paralysis.  It  is  probable  that  on 
his  first  admission  he  must  have  had  prior  thereto  an  attack 
of  cerebral  congestion  (congestive  attack),  and  that  recovery 
from  it  was  taking  place  even  before  his  admission. 

Case  with  Epileptiform  Seizures.     Rapid  Course. 

John  W.,  set.  45.  First  symptom,  restlessness  at  night. 
This,  by  the  way,  is  a  frequent  first  warning.  Epileptiform 
fits  followed.  Sexual  desire  very  strong,  but  could  not  be 
gratified.  Naturally  temperate  and  careful  of  money. 
Slight  accident  to  left  foot  two  years  previously.  Tabic 
gait,  weaker  on  left  side  ;  grip  jerky  and  spasmodic  in  left 
hand ;  speech  slow,  interrupted,  and  slurred.  Absence  of 
tendon  reflex.  Left  eye  blind  from  injury.  Died  a  year 
after  admission. 


222  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

Case  probably  Syphilitic.     Mental  Integrity  very  good. 

D.  N.,  get.  59.  Probably  a  syphilitic — at  any  rate,  a 
gonorrhoeal  history.  Excited  and  exalted.  Declared  this 
to  be  heaven,  and  a  few  days  later  said  he  had  been  round 
the  world  in  the  last  two  da5'S.  Pupils  small,  immobile  ; 
tongue  protrusion  jerky ;  speech  thick  and  interrupted. 
Said  he  had  a  letter  about  his  wife,  and  that  she  was  dead 
— a  delusion.  Pains  in  right  side,  followed  by  hemiplegia. 
Accessions  and  recessions  of  strength  from  day  to  day. 
For  a  general  paralytic,  was  particularly  accurate  in 
observing  and  reporting  his  symptoms.  Hallucinations  of 
sight  and  taste.  Bedsores  on  right  buttock,  blisters  (trophic 
neurosis)  running  down  right  arm  and  wrist,  later  on  left 
arm,  then  coma,  convulsions,  and  death. 

Case  with  Motor  Syinptouis  the  more  General  and  Prominent  at 

the  Outset. 

M.  E.,  set.  41.  It  would  have  been  rather  difficult  to 
certify  this  man  insane  a  year  ago,  for  he  possessed  a  fair 
share  of  intelligence,  was  quiet,  well  conducted,  and  a 
useful  member  of  society.  All  that  could  be  found  wrong 
mentally  was  in  his  manner  and  carriage  rather  than  in 
anything  he  said.  He  looked  a  man  who  thought  very  well 
of  himself,  but  the  mental  failure  now  very  perceptible — the 
weakness  of  memory,  want  of  method,  confusion  of  ideas, 
and  delusions  of  exalted  character — was  not  at  first  notice- 
able. The  nervous  phenomena  gave  a  clue  to  the  nature 
of  the  case. 

The  pupils  were  equal,  contracted  regular  ;  the  consensual 
light  reflex  slight  and  slow  :  the  direct  light  reflex  was  good, 
the  accommodation  good,  and  there  was  no  colour  blindness. 
Reflex  dilatation  was  impaired,  but  fairly  marked  on  shout- 
ing or  electrical  stimulation.  Smell  good,  hearing  fairly 
good.  Dynamometer  R.  100,  L.  go.  Knee  reflexes  in"^ 
creased.  Superficial  reflexes  and  ankle  clonus  absent. 
Tongue  and  speech  tremulous,  and  the  facial  muscles 
showed  fine  tremors  when  he  was  the  least  excited.     A  few 


GENERAL  PARALYSIS  OF  THE  INSANE  223 

months  after  admission  he  had  a  faint  and  momentary 
seizure,  probably  epileptiform,  and  since  then  he  has  de- 
generated mentally. 

General  Paralysis  not  at  first  suspected.     Grandiose  Delusions  for 
Five  Years  without  marked  Motor  Symptoms. 

R.  S.,  aet.  36.  This  man  had  been  in  America  for  some 
years.  On  admission  he  had  the  delusions  that  he  was  a 
general  and  owned  property  in  the  neighbourhood,  and  shares 
in  several  public  companies.  The  only  motor  symptoms 
observed  for  years  were  small  pupils,  tremor  of  the  tongue 
and  of  the  left  depressor  alae  nasi.  There  were  cicatrices, 
skin  eruptions  and  other  conditions  suggestive  of  syphilis, 
but  not  very  conclusive.  He  suffered  from  strange  sensa- 
tions, particularly  he  averred  at  the  site. of  these  cicatrices,  a 
feeling  as  if  a  battery  was  connected  with  these  spots.  He 
wanted  mustard  for  his  mouth  '  to  heat  the  nerve.'  He 
developed  delusions  of  persecution,  got  more  and  more 
shaky  and  tremulous,  had  an  attack  of  right  hemiplegia,  after 
which  his  speech  became  more  affected,  and  from  that  time 
onward  the  downward  general  paralytic  course  was  rapid. 
He  died  after  being  nine  years  insane. 


CHAPTER  XII. 

EPILEPTIC  INSANITY. 

The  general  mental  character  of  the  epileptic  apart  from  insanity — Rules 
for  guidance  in  giving  a  prognosis  as  to  the  probable  development 
of  insanity  in  cases  of  epilepsy — In  epileptic  insanity  we  must  have 
regard  to  two  phases  of  the  disease  :  (a)  the  every-day  mental  habit, 
(^)  breaks  in  the  continuity  of  that  habit — Types  of  mental  habit 
and  general  mental  character  and  disposition  of  epileptics — Mental 
disturbance:  (i)  before  fits,  (2)  after  fits,  (3)  in  place  of  or  inde- 
pendent of  fits — The  nature  of  the  mental  disturbance — Diversities 
of  mental  disturbance — Charts — Diagnosis — Prognosis  {a)  regarding 
risks  of  excitement  and  violence  in  relation  to  attacks,  (d)  as  to  the 
cure  of  the  epilepsy,  (c)  as  to  the  cure  of  epileptic  insanity— Treat- 
ment— Clinical  illustrations. 

Epilepsy  with  Sanity. 

This  term  embraces  all  forms  of  epilepsy  not  considered 
mentally  peculiar  to  any  serious  extent.  It  must  be  remem- 
bered that  the  epileptic  reputedly  sane  is  rarely  as  other  men 
in  his  mental  condition  ;  there  is  usually  more  or  less  mental 
twist.  And  yet  we  know  that  many  epileptics  never  become 
insane,  for  it  is  reckoned  that  about  one-half  of  them  escape 
this  climax  of  a  most  terrible  disease.  Of  this  half,  however, 
it  is  true  that  they  almost  invariably  exhibit  in  their  mental 
lives  a  more  or  less  diminished  reflex  of  the  mental  symptoms 
of  their  more  unfortunate  brethren.  Like  them  they  are 
liable  to  attacks  of  irritability  and  passion  before  or  after 
fits,  are  sometimes  subject  to  hallucinations,  periods  of 
mental  confusion,  suspicion,  and  stupidity,  and  frequently 
are  disturbed  by  restless,  wandering  impulses.  In  addition 
they  are  often  characterized  in  their  regular  everyday  lives 
apart  from  fits  altogether — by  a  changeableness  of  dispo- 


EPILEPTIC  INSANITY  225 

sition,  a  strain  of  ill-regulated  religious  feeling  all  the  more 
astonishing  that  the  moral  nature  is  ill-balanced,  and  the 
sense  of  truth  and  right  is  by  no  means  acute.  They  are 
apt  to  be  contentious  and  quarrelsome,  and  some  of  the 
most  unseemly  church  disputes  that  occur  from  time  to 
time  are  stirred  up  with  m.alignity  and  unbridled  passion 
by  epileptics.  Not  infrequently  is  observed  a  slowness  and 
hesitancy  of  speech,  more  often  noticeable  in  epileptic 
insanity.  Ross  and  Wylie  have  drawn  attention  to  aphasia 
after  fits,  and  among  the  epileptic  insane  disorders  of  speech 
are  even  more  general. 

Epileptic  Insanity. 

From  this  description  is  excluded  epileptic  idiocy  and 
imbecility.  A  grave  question  regarding  epilepsy  at  any 
time,  but  especially  in  youth,  is  the  risk  of  insanity  super- 
vening sooner  or  later.  The  prognosis  is  difficult  because 
so  many  escape,  and  because  remarkable  exceptions  tend  to 
upset  all  preconceived  doctrines  now  and  again.  Savage 
relates  the  case  of  a  dull  boy  who  at  puberty  began  to  take 
fits,  and  brightened  up  intellectually ;  he  forged  ahead  at 
school,  ceased  to  be  epileptic  in  three  years  from  the  first 
attack,  and  is  now  a  strong  healthy  man.  He  ought  to 
come  forward  as  a  clinical  illustration  of  a  most  erratic 
development.  This  phenomenon  notwithstanding,  we  may 
accept  the  following  rules  as  guides  to  prognosis  : 

1.  The  earlier  the  appearance  of  epilepsy,  the  sooner  does 
a  mental  aberration  or  defect  show  itself,  and  the  more 
serious  becomes  its  character. 

2.  Where  epilepsy  appears  late,  the  mind  is  not  so  seriously 
involved,  and  the  intellect  is  less  impaired  as  a  sequence.  If 
insanity  supervenes,  it  is  usually  in  the  form  of  maniacal 
attacks,  though  sometimes  the  form  is  melancholia. 

3.  When  epilepsy  appears  after  maturity,  and  insanity 
soon  follows,  organic  changes  in  the  brain  or  neighbouring 
structures  are  more  evident  and  extensive;  there  is  probably 
gross  brain  disease. 

Epileptic  insanity  differs  from  general  paralysis  almost  to 
an  opposite  extreme  in  the  density  and  areas  of  its  distribu- 

15 


226  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

tion.  Sparsely-populated  districts  have  their  full  share  of 
cases,  sometimes  more  than  dense  centres  of  population ; 
and  this  is  also  true,  and  in  a  higher  degree,  of  epileptic 
idiocy  and  imbecility.  The  number  of  epileptics  in  English 
asylums  is  stated  by  Savage  as  9  per  cent. ;  the  number  in 
Scotch  asylums  is  about  5  per  cent.  The  female  percentage 
is  lower  than  the  male,  and  the  death-rate  is  higher  for  men 
than  women.  The  occurrence  of  epileptic  insanity  is  more 
frequent  during  puberty  and  adolescence  than  in  later  life. 

^Etiology. 

The  causes  of  epilepsy  are  presumptive  causes  of  epileptic 
insanity.  Epilepsy,  idiocy,  and  insanity  are  not  infrequent 
in  the  same  family  history.  I  have  notes  of  one  family 
where  the  mother,  now  an  old  woman,  has  been  epileptic 
for  the  greater  part  of  her  life,  with  well-marked  mental 
characteristics  of  epilepsy,  but  no  insanity.  Of  two  sons, 
one  is  a  sane  epileptic ;  the  other,  recently  deceased,  was 
hemiplegic  since  boyhood  from  cranial  injury,  later  became 
subject  at  long  intervals  to  epileptic  seizures,  and  after  he 
came  to  manhood  insanity  appeared.  In  middle  and  advanced 
life  we  find  epilepsy,  and  its  sequel  insanity,  as  the  result  of 
cranial  injuries,  syphilis,  alcoholic  excess,  mental  strain,  and 
shock.  It  has  been  known,  though  rarely,  to  end  in  general 
paralysis,  and  chronic  insanity  sometimes  has  epilepsy  grafted 
into  it. 

It  is  taken  for  granted  that  in  the  majority  of  cases 
epileptic  insanity  is  a  natural  result  of  epilepsy ;  in  other 
words,  that  the  neuro-vascular  agitations  of  the  epileptic 
seizures  gradually  induce  mental  instability,  which  finally 
precipitates  insanity.  To  still  further  add  to  the  perplexities 
of  the  argument,  the  undermining  process  is  more  potent  in 
the  male  than  the  female.  It  is  probable  that  other  causes 
have  to  be  reckoned  with — family  history,  sexual  excess,  and 
alcoholic  excess,  for  example,  apart  from  the  factor  of 
epilepsy. 

If  we  look  at  epilepsy  and  epileptic  insanity  in  their 
broadest  bearing,  not  having  regard  merely  to  typical 
instances  which   cramp  our  views,  but  observing  carefully 


EPILEPTIC  INSANITY  227 

the  endless  varieties  of  the  disease,  and  the  analogues  seen 
in  other  forms  of  insanity,  and  in  certain  physiological 
periodic  functions,  the  impression  becomes  clear  that,  while 
the  identity  of  the  underlying  processes  may  differ,  there  is 
in  all  cases  a  law  of  gathering  tension  and  relief,  a  charge 
and  discharge  of  energy.  The  startling  suddenness  of  the 
epileptic  seizure,  its  unique  manifestations,  make  it  appear 
std  generis ;  but  it  is  merely  the  louder  and  more  striking 
emphasis  of  a  general  law  which  may  be  physiological  or 
pathological.  The  degree  of  tension  is  as  the  resistance, 
and  relief  may  sometimes  find  its  way  through  unaccustomed 
channels.  Clouston  disputes  the  view  of  Hughlings  Jackson, 
that  in  cases  oi  petit  mal  and  slight  convulsions  the  explosion, 
not  finding  vent  in  a  motor  form,  is  more  apt  to  extend  up 
into  mental  centres.  He  objects  to  the  term  '  explosion  '  as 
applied  to  anything  mental.  Call  the  term  what  you  please, 
the  fact  is  as  stated  by  Hughlings  Jackson,  and  experienced 
observant  attendants  will  tell  you  in  the  wards,  pointing  to 
individual  cases  of  epileptic  excitement,  that  the  patient  has 
only  had  'choked-off'  fits,  and  that  as  soon  as  a  major  fit 
appears  the  mental  symptoms  will  subside. 

Symptoms. 

In  epileptic  insanity  we  have  to  consider  two  phases  of 
the  disease :  first,  the  everyday  mental  habit  and  character 
of  the  patient  ;  second,  the  breaks  in  the  continuity  of  that 
mental  habit.  The  breaks  are  occasioned  by  or  associated 
with  the  onset  of  epileptic  seizures,  or  they  may  be  mental 
incidents  such  as  larvated  epilepsy.  The  accompanying 
charts  illustrate  from  actual  cases  the  chequered  life  history 
of  the  epileptic. 

The  first  phase,  what  is  here  called  the  every-day  mental 
habit  and  character,  may  sum  up  three-fourths  of  the  man's 
life  or  more,  but  its  duration  varies  in  the  same  individual  at 
different  times.  In  a  sense  it  is  his  normal  state,  for  it  is 
the  nearest  approach  to  mental  health  in  which  we  find 
him.  Here  is  an  exaggeration  of  the  mental  peculiarities 
observed  in  the  sane  epileptic,  and  under  the  mental  habit 
we  recognise  at  least  five  different  types  : 

15—2 


228  CLINICAL  MANUAL  OF  MENTAL  DISEASES 


Type  (a). — Sulky  or  serious,  irritable,  impulsive,  quarrel- 
some, obstinate,  unreasonable,  full  of  complaints,  vindictive, 
and  at  times  violent,  but  devotional  and  attentive  to  religious 
forms  and  ceremonies.  The  greater  number  belong  to  this 
t3-pe. 

Type  (b). — Sociable,  helpful,  companionable,  bright  and 
genial ;  religiosity.  A  smaller  number  belong  to  this  type. 
These  two  types  may  be  seen  at  different  times  in  the  same 
individual. 

Type  (c). — Agreeable  but  deceitful,  and  treacherous,  re- 
sentful, mischief-making,  stirring  up  strife ;  religiosity.  A 
fair  proportion  of  this  class. 

Type  {d).  —  Sad  of  aspect,  inclined  to  melancholy  and 
suicide  ;  religiosity.     A  few  come  under  this  head. 

Type  (e). —  Demented,  no  speech,  limited  intelligence, 
mental  reaction  almost  nil,  irritability,  sometimes  nil,  at 
other  times  in  all  its  primary  force,  ideation  slow.  All  who 
survive  long  enough  ultimately  reach  this  stage. 

Epileptics  are  noted  for  their  cleanliness  and  tidiness. 
They  like  to  be  tight  about  the  neck,  and  in  bed  they  keep 
their  heads  under  the  bedclothes,  which  are  features  the 
opposite  of  what  one  would  expect.  They  are  fond  of 
collecting  and  hoarding  worthless  articles,  and  this  they 
often  do  automatically  when  dazed  after  lits.  The  epileptic 
is  fanciful  about  his  health,  thinks  a  great  deal  about  him- 
self and  what  he  shall  eat.  He  is  gluttonous,  and  often 
dissatisfied  with  his  meals  and  hard  to  please.  However 
unreasonable  and  irritable  he  may  be  in  his  habitual  disposi- 
tion with  others,  he  is  most  patient,  tolerant,  and  sympathetic 
wdth  his  fellow-epileptics  when  in  their  epileptic  state  or 
furor.  His  helpfulness  and  tact  are  wonderful  in  such  cases. 
As  the  disease  progresses,  the  mind  becomes  more  and  more 
clouded,  memory  fails,  initiative  is  lost,  and  he  does  things 
only  when  he  is  told  to  do  so.  There  is  an  increasing 
mental  ablation  ;  there  is  no  volition  or  active  regulating 
intelligence.  The  emotions  are  gradually  wiped  out,  and 
the  angry  passions  are  reduced  in  frequency  and  intensity. 
Their  speech  is  often  slow  (bradylalia) ;  sometimes,  as  when 
excited,  it  is  rapid,  but  the  words  may  not  be  articulated 


EPILEPTIC  INSANITY  229 

perfectly.  Their  utterance  is  peculiar  to  epilepsy,  and  quite 
different  from  that  of  general  paralysis,  often  slowly  drawled 
out,  with  frequent  stops  as  if  certain  words  hung  fire  for  a 
moment.  But  there  is  rarely  observed  the  convulsive  or 
trembling  excitement  of  the  facial  muscles  seen  in  general 
paralysis,  or  in  stuttering.  The  speech  defect  may  be  tem- 
porary, e.g.,  after  fits.     It  may  be  amnesic,  or  it  may  be  motor. 

The  breaks  in  the  continuity  of  the  mental  habit,  giving 
to  the  disease  its  most  striking  character,  are  due  to  mental 
disturbance  or  epileptic  seizures.  Excitement  may  occur 
without  seizures,  and  vice  versa ;  but  it  is  the  rule  to  find 
the  one  in  the  wake  of  the  other. 

Mental  disturbance  may  occur  :  (i)  before  fits  ;  (2)  after 
fits  ;  (3)  in  place  of  or  independent  of  fits. 

Mental  disturbance  before  fits  is  often  of  an  acute  maniacal 
type ;  sometimes  it  may  consist  of  mild  exaltation  or  hallu- 
cinations, rarely  there  is  suicidal  depression.  After  a  day  or 
two,  the  fits  replace  the  excitement,  stupor  follows  for  longer 
or  short  periods,  and  the  patient  then  returns  to  his  usual  habit. 
The  mental  disturbance  may  be  so  brief  as  to  be  merely  a 
mental  aura ;  thus,  a  patient  barks  hke  a  dog,  another  begins 
to  play  tricks  on  other  patients  ;  one  cries  out  that  he  sees 
eight  beasts  before  him,  another  sings  psalms  and  hymns  ; 
one  sees  a  woman  coming  to  strike  him  with  a  blue  hammer, 
another  sees  angels  on  a  wall  waiting  to  take  him  to  heaven 
when  he  dies.  In  some  cases  the  mental  disturbance  is  so 
transient  and  so  rapidly  followed  by  a  fit  that  it  may  be 
regarded  as  a  true  mental  aura. 

Mental  disturbance  after  fits  is  more  frequent.  A  patient 
may  take  one  or  more  fits  before  the  mental  furor  breaks 
out,  usually  several  fits  ;  but  it  must  be  borne  in  mind  that 
a  paroxysm  of  excitement  is  not  determined  merely  by  the 
number  of  the  fits.  It  is  still  a  moot  point  whether  petit  mat 
is  not  as  productive  of  excitement  and  violence  as  grand  mal. 
I  have  endeavoured  by  careful  inquiry  to  gather  evidence 
that  would  justify  a  ruling  on  the  subject ;  but  Nature  is 
impatient  of  rulings.  I  find  that  in  the  male  wards  petit  mal 
is  regarded  as  provocative  of  excitement  and  impulse  as 
much  as  grand  mal,  while  in  the  female  wards  the  patients 


230  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

are  said  to  be  more  amenable  after  minor  iits,  but  seem  to 
deteriorate  mentally  at  a  more  rapid  pace  than  those  who 
are  more  subject  to  major  fits  than  minor.  This  confirms 
m}"  experience  in  another  asylum.  Nocturnal  epilepsy  seems 
to  be  graver  as  regards  the  amount  of  mental  disturbance 
which  follows  it  than  diurnal  epilepsy.  As  illustrating  the 
mental  outcome  in  relation  to  particular  phases  of  epileptic 
seizure,  the  following  observation  by  a  brother  regarding  a 
male  patient  is  very  much  to  the  point :  '  When  the  fits  come 
regular  the  mind  is  better,  when  irregular  the  mind  is 
worse.'  A  certain  allowance  has  to  be  made  for  the  in- 
dividual. Those  who  know  him  best  can  best  prognosticate. 
Epileptic  insanity  differentiates  beyond  the  reach  of  general 
principles  in  a  variety  of  waj's. 

Mental  Disturbance  without  Fits. — This  form  is  one  regarding 
which  a  good  deal  of  controvers}-  has  arisen,  and  it  is  some- 
times confounded  with  the  epilepsie  larvee  (masked  epilepsy) 
of  Esquirol  and  Morel  where  a  seizure  has  been  slight,  and 
succeeded  by  automatism  in  a  subconscious  state  of  which 
there  is  no  recollection  after,    ^^^e  will  take  these  separately. 

(a)  Mental  Disturbance  in  Place  of  Fits. — The  existence  of 
this  form  has  been  denied  b}'  some  eminent  authorities,  who 
assert  that  there  must  have  been  a  preceding  seizure  which 
escaped  detection.  Some  force  is  given  to  this  objection  by 
the  fact  that  after  attacks  of  petit  mal  a  mental  disturbance 
breaks  out  in  an  exceedingly  acute  form,  and  attended  with 
violence.  It  is  contended  that  man}'  attacks  of  petit  mal, 
being  transient  and  shadowy,  must  escape  notice,  and  that 
it  is  practically  impossible  to  prove  that  there  has  been  no 
such  seizure.  On  the  other  hand,  well-known  cases  are  on 
record  of  epileptics  becoming  suddenly  excited  in  church, 
preaching  and  declaiming,  then  quickly  subsiding,  and  being 
unconscious  of  the  occurrence  afterwards.  It  is  difficult  to 
prove  a  negative  :  but  with  trained  attendants  and  nurses 
assisting,  the  evidence  is  stronger  to-day  in  favour  of  attacks 
of  mental  derangement  without  precedent  petit  mal  than  it 
was  some  years  ago.  It  must  not  be  supposed  that  all 
excitement  without  evidence  of  fits  is  of  this  form.  There 
is  more  or  less  potential  excitement  in  epileptics  at  all  times. 


EPILEPTIC  INSANITY  231 

unless  they  are  demented,  and  they  may  sometimes  be  quickly 
roused  by  external  causes. 

(b)  Epilepsie  Larvee. — As  Savage  points  out  (Tuke's  '  Dic- 
tionary of  Psychological  Medicine '),  there  is  doubt  as  to 
whether  the  automatism  is  a  part  of  the  epileptic  discharge, 
or  a  post-epileptic  state.  Epileptic  automatism,  which  has 
been  confounded  with  somnambulism,  is  often  nocturnal  in 
character  and  of  grave  significance,  as  homicidal,  suicidal, 
or  other  acts — theft,  for  example — may  be  committed  in 
this  state,  the  patient  being  more  or  less  unconscious,  and 
memory  being  a  blank  afterwards.  Savage  has  recorded  a 
case  in  Brain  of  whom  it  was  said  that  his  relatives  had 
been  able  to  get  him  to  sign  cheques  and  do  other  things 
with  his  property  while  in  this  state.  I  have  had  a  few 
cases  of  this  kind ;  but  they  are  rare,  and  the  automatism 
is  the  distinguishing  feature.  One  was  that  of  a  gentleman 
who  lost  consciousness  in  a  certain  street,  and  recovered  it 
a  mile  further  east.  There  was  no  fall,  no  disordered  or 
soiled  clothes,  and  it  is  probable  that  it  was  a  case  of  petit 
mal  followed  by  automatism.  Sibbald,  referring  to  this 
subject  (Quain's  '  Dictionary  of  Medicine,'  last  edition), 
says  :  'In  this  state  the  patient  will  walk  long  distances 
without  object,  steal  or  destroy  articles  in  an  unaccountable 
way,  and  will  commit  suicide  or  homicide  with  apparent 
deliberation.  They  seem  insensible  to  everything  that  does 
not  fall  in  with  their  dominant  idea  or  impulse.  The  patients 
are  as  in  a  waking  dream.'  When  they  wake  out  of  it,  they 
feel  as  if  they  had  had  a  bad  dream. 

The  Nature  of  the  Mental  Disturbance. — The  typical  epileptic 
furor,  as  most  frequently  seen,  is  that  which  succeeds  fits. 
The  patient  may  be  disturbed  out  of  his  post  -  epileptic 
stupor,  and  without  warning  make  a  spring  at  someone. 
The  excitement  may  burst  out  suddenly,  or  it  may  gather 
force,  like  a  storm  on  the  horizon  coming  nearer  and  nearer. 
It  is  blind  fury ;  reason  has  fled.  The  man  is  ready  to  fight 
with  his  own  shadow.  There  are  two  features  which  have 
been  specially  noticed  and  emphasized  by  Jules  Falret : 
(i)  The  greater  rapidity  of  the  invasion  compared  with  other 
forms  of   mania ;    (2)   the   absolute    resemblance  of   all    the 


232  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

attacks  in  the  same  patient,  even  in  every  detail.  It  re- 
sembles ordinary  acute  mania;  but  differs  in  being  more 
violent  and  impulsive,  in  being  more  frequently  complicated 
w^ith  hallucinations,  especially  of  sight  and  hearing,  and  in 
being  of  shorter  duration. 

Two  outstanding  symptoms  of  the  furor  are  irritability 
and  impulsiveness.  There  may  be  no  personal  animosity 
to  anyone  in  particular  ;  or,  on  the  other  hand,  there  may 
be  a  suspicion,  a  smouldering  hatred  before  a  fit,  which  is 
revived  after  it  with  maniacal  intensity.  There  is  a  state 
of  high  nervous  tension  in  either  case,  an  irritability  that 
cannot  bear  to  be  ruffled  in  the  faintest  degree.  The  acci- 
dental rubbing  against  his  elbow,  a  creaking  noise  on  the 
floor,  a  scraping  noise  with  a  chair,  produce  a  mental  irrita- 
tion which  is  instantaneously  transformed  into  a  violent 
impulse.  In  some  cases  the  sudden  rise  of  the  storm  is  seen 
before  as  yet  an  object  on  which  to  vent  it  comes  across 
the  range  of  vision.  Then  any  object  will  do,  animate  or 
inanimate.  You  may  frequently  see  epileptics  swoop  down 
upon  the  most  unoffending  victims.  When  the  dread  spell 
is  broken,  and  the  man  comes  to  himself,  there  is  no  recol- 
lection ;  it  is  all  a  blank. 

How  far  or  how  often  the  excitement  and  impulsive  violence 
of  epileptic  insanity  are  the  outcome  of  passion  with  no  mental 
initiative,  and  to  what  extent  and  how  often  intellectual  dis- 
turbance plays  the  initiative  part,  must  be  partly  conjecture. 
This  fact,  however,  is  certain,  even  though  not  always  clearly 
expressed  by  the  patients,  that  hallucinations  give  rise  to 
imperative  conceptions,  that  they  are  sometimes  terrifying 
and  maddening  in  their  effects,  and  that  probably  the  un- 
restrained violence  is  largely  due  to  sensory  disturbance  of 
this  kind.  The  hallucinations  most  common  are,  in  their 
order  of  frequency — sight,  hearing,  smell.  In  the  state  of 
furor,  be  it  long  or  short,  there  is  always  danger  of  homicidal 
violence.  The  epileptic  in  this  state  is  not  responsible.  The 
germ  of  the  morbid  impulse  may  be  suspicion  ;  the  epileptic 
is  an  easy  prey  to  such  a  state  of  mind  ;  the  merest  sugges- 
tion gets  admission  to  his  mind  at  once.  After  fits  there  is 
muscular  fatigue,  a  feeling  of  having  been  beaten,  aches  and 


EPILEPTIC  INSANITY  233 

pains,  mysterious  sensations  in  the  abdomen,  in  the  head, 
or  anywhere  else.  A  man  crosses  the  field  of  vision  before 
the  epileptic  has  come  to  his  right  mind.  He  is  not  himself 
yet :  like  a  flash  without  reason,  the  sensation  and  the  object 
are  associated.  From  suspicion  to  impulse  is  but  another 
flash,  and  in  a  moment  there  may  be  murder. 

Epileptics,  when  apparently  out  of  the  maze  and  in  a  right 
state  of  mind,  are  given  to  making  groundless  charges  of  ill- 
usage  against  their  attendants,  and  in  some  cases  a  personal 
ill-will  suspended  by  the  onset  of  a  fit  may  be  revived  after 
it  with  fresh  intensity.  As  already  said,  they  may  be  acting 
under  the  spell  of  hallucinations — voices  impelling  them 
to  kill,  visions  of  attack  that  compel  them  to  defend  them- 
selves with  bloody  ferocity,  or  there  may  be  actual  delusions 
of  persecution  which  prompt  the  assault.  Happily  for  the 
patient,  almost  everything  is  a  blank  afterwards  ;  but  this 
advantage  militates  against  our  obtaining  a  complete  state 
of  the  case.  In  a  case  of  murder  committed  by  an  epileptic, 
I  was  unable  to  rouse  any  gleam  of  recollection  ;  nor  imme- 
diately subsequent  to  the  event,  when  daylight  streamed  into 
the  cell  where  his  victim  and  he  had  been  locked  in  together, 
did  the  sight  disturb  him  in  the  least,  or  awaken  any  recol- 
lection. Dr.  Clouston  relates  the  case  of  a  young  epileptic 
whose  habitual  disposition  was  friendly,  but  who  conceived' 
a  deadly  hatred  of  him  after  fits.  On  one  post-epileptic 
occasion  he  was  found  alone  with  another  patient  contriving 
a  weapon  with  which  to  kill  the  doctor.  When  he  recovered 
from  the  attack  he  had  no  recollection  of  it  whatever.  Ac- 
cording to  Falret,  the  termination  is  as  sudden  as  the  inva- 
sion. This  statement  may  be  taken  with  reserve,  for  there 
is  sometimes  a  dazed  condition  lasting  for  hours  or  days 
after  an  acute  attack  of  excitement,  and  the  patient  is  not 
to  be  trusted. 

Diversities  of  Mental  Disturbance. — The  preceding  descrip- 
tion is  good  for  well-marked  typical  cases,  but  there  are 
many  varieties  of  epileptic  insanity  which  bear  only  a  family 
likeness  to  it.  Nor  must  the  absolute  resemblance  of  the 
attack  to  its  predecessors  be  too  strictly  insisted  upon, 
although    the  statement  is    remarkably  rear  the  truth.     A 


234  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

patient  may  have  a  series  of  minor  fits  at  one  time,  and  of 
major  at  another  ;  but  the  mental  sequels  are  not  necessarily 
the  same.  He  may  have  suffered  from  constipation  during 
one  attack  of  excitement,  and  have  his  bowels  well  cleared 
out  previous  to  another ;  the  mental  condition  in  the  one 
case  is  likely  to  be  more  acute  and  prolonged  than  in  the 
other.  Further,  it  must  be  remembered  that  occasionally 
mental  disturbance  precedes  and  succeeds  fits  in  the  same 
individual. 

The  maniacal  form  is  the  most  typical.  It  may  be 
delusional  and  attended  with  hallucinations,  it  may  be 
characterized  merely  by  irritability  and  impulsiveness,  or  it 
may  be  distinguished  by  symptoms  of  loud  exaltation,  a 
happy  religious  feeling,  the  singing  of  psalms  and  hymns, 
and  quarrelsomeness  if  interfered  with.  A  melancholic  form 
is  rare,  and  especially  so  with  marked  suicidal  impulse. 
According  to  Clouston,  this  usually  results  from  voices  telling 
the  patient  to  commit  the  act.  The  most  determined  case 
I  have  known — a  woman — suffered  from  suicidal  depression 
before  fits,  and  was  safe  once  the  fits  appeared.  There  were 
no  hallucinations  in  her  case.  Masturbation  has  been 
alleged  as  a  habit  frequently  indulged  in  by  epileptics,  but 
my  experience  does  not  accord  with  this  statement,  except 
in  the  case  of  congenital  epileptics  of  the  idiot  or  imbecile 
class,  and  sometimes  when  waking  up  after  fits. 

A  case  to  which  I  will  now  refer  illustrates  the  diffuse 
nature  of  epilepsy,  and  the  probability  that  the  borders  of 
the  lesion  are  not  so  exclusively  confined  to  motor  areas  as 
many  suppose.  Sam  A.  is  of  an  epileptic  family  ;  his  brother 
John  from  childhood  has  been  subject  to  genuine  fits  of 
motor  epilepsy,  and  has  been  under  my  care.  Sam  is 
subject  to  periodic  attacks  in  two  stages — first,  sensori- 
melancholic ;  second,  motor  excitement  not  convulsive.  In 
the  first  stage  the  symptoms  might  be  those  preceding  an 
attack  of  epilepsy,  viz.,  melancholy,  crj-ing  out  that  he  is  to 
be  killed,  hallucinations  of  sight,  reads  his  doom  on  the 
ceiling,  refuses  food.  In  the  second  there  is  restlessness, 
continual  hopping  about  from  one  place  to  another;  the  melan- 
cholic symptoms  have  disappeared,  he  talks  incoherently,  and 


EPILEPTIC  INSANITY  235 

frequently  bursts  into  laughter.  There  has  never  been 
observed  an  attack  of  petit  mat,  or  a  convulsive  seizure ;  but 
having  regard  to  the  family  history  of  epilepsy,  the  periodicity 
of  the  attacks,  their  sameness,  and  the  predominance  of  the 
hallucinations  at  one  time,  and  motor  excitement  at  another, 
it  seems  probable  that  this  is  a  phase  of  the  epileptic 
neurosis. 

Diagnosis. 

The  diagnosis  of  epileptic  insanity  is  easy.  To  establish 
the  fact  of  epilepsy  is  the  chief  point  of  attention.  Hysterical 
fits  may  simulate  epileptic,  and  epileptics  not  infrequently 
simulate  epileptic  seizures  themselves.  There  may  some- 
times be  a  difficulty  in  differentiating  from  general  paralysis, 
but  the  mental  symptoms  are  quite  distinct ;  the  resemblance 
of  speech  may  sometimes  be  puzzling,  but  the  other  motor 
features  are  absent.  It  may  also  be  necessary  to  distinguish 
from  syphilitic  disease  of  the  brain,  but  the  syphilitic  history, 
the  partial  nature  of  the  convulsive  seizures,  the  absence  of 
the  motor  troubles  and  nocturnal  cephalalgia  which  charac- 
terize syphilitic  affections,  will  aid  the  diagnosis. 

Prognosis. 

{a)  Regarding  the  risks  of  excitement  and  violence  in  relation 
to  attacks.  It  is  not  possible  to  speak  with  a  clear  note  of 
authority  in  all  cases.  It  is  well  to  study  individual  cases  in 
the  light  of  previous  experience  of  such  cases,  for  there  is  a 
tendency  to  repetition  and  periodicity  in  the  mental  attacks. 
This  tendency  is  broken  up  somewhat  by  treatment,  espe- 
cially the  exhibition  of  the  bromides.  Where  there  has  been 
a  long  spell  of  freedom  from  fits,  and  they  appear  in  a  series, 
long  or  short,  the  probability  is  that  a  mental  attack  of 
unusual  severity  is  imminent.  In  females  special  precautions 
should  always  be  taken  at  the  approach  of  the  menstrual 
periods.  In  some  females  fits  only  come  on  in  relation  to 
this  function,  but  not  of  necessity  at  any  particular  stage. 

(&)  The  cure  of  epilepsy  is  practically  hopeless  after  puberty, 
although  there  are  some  astonishing  exceptions  ;  but  not  so 
during  childhood  and  puberty.     With  very  great  care  in  the 


236  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

supervision  of  education,  diet,  and  physical  training,  much 
may  be  done  for  the  incipient  epileptic  in  early  life. 

(c)  The  cure  of  epileptic  insanity  may  be  effected  where  the 
vice  of  masturbation  is  not  a  confirmed  habit,  and  where 
there  is  no  evidence  of  gross  lesion  of  the  nervous  system. 
The  most  successful  cases  are  those  in  which  insanity  appears 
during  the  middle  period  of  life,  and  without  grave  organic 
disease.  The  prognosis  is  bad  if  there  is  evidence  of  mental 
failure,  the  signs  of  oncoming  dementia.  If  the  fits  are 
diurnal  and  of  the  major  type,  the  prognosis  is  said  to  be 
better  than  when  they  are  nocturnal  or  of  the  minor  form. 

Treatment. 

{a)  Of  Epilepsy. — This  is  a  question  much  disputed.  Some 
asylum  physicians  believe  that  the  bromides  hasten  the 
down-grade  of  the  epileptic  mentally  and  physically.  My 
experience  confirms  Clouston's,  but  with  a  reservation. 
Clouston  appears  to  me  to  state  the  case  in  favour  of  the 
bromides  too  strongly.  In  deference  to  the  strong  views  of 
others,  I  have  stopped  the  use  of  bromide  of  potassium  for  a 
year,  and  the  result  has  been  an  increase  of  the  day-fits  by 
60  per  cent.-,  and  an  increase  of  the  night-fits  by  14  per  cent. 
My  experience  is  that  of  others,  that  only  day-fits  are  bene- 
fited by  bromide,  and  that  the  potassium  salt  is  the  one 
most  generally  successful.  It  is  usually  given  in  30  grain 
doses  four  times  a  day.  Epileptics  are  very  punctual  in 
turning  up  for  their  dose ;  they  believe  in  bromide  as  much 
as  in  their  Bible.  Bromide  is  a  drug  that  should  be  given 
warily  in  the  case  of  children,  and  also  at  puberty,  for  it 
often  does  harm  rather  than  good.  It  is  a  wise  precaution 
in  all  cases  to  intermit  it  every  fourth  week,  or  otherwise  as 
may  be  indicated.  Nor  is  it  desirable  to  push  it  where  the 
fits  are  infrequent — say  one  in  a  month — if  the  epileptic 
neurosis  is  clearly  established.  I  have  stopped  it  for  three 
years  in  such  a  case,  with  the  result  that  the  patient  is  better 
than  when  he  was  ringing  the  changes  on  all  the  bromides, 
separately  and  in  combination,  and  had,  under  the  experienced 
advice  of  an  eminent  physician,  tried  other  drugs  and  com- 
binations as  well.     Borax  in   15  to  30  grain  doses  several 


Plate  v.— EPILEPTIC  INSANITY.     CHRONIC  MANIA. 


IIYSTERO-EPILErSY. 


epileptic  insanity 
(amnesic  and  ataxic  aphasia). 


EPILEPTIC    IDIOCY. 


To/ace  />.  237. 


chronic    MANIA. 


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AprilW 


EPILEPTIC  INSANITY  237 

times  a  day  has  been  recommended  by  Gowers.  A  course 
of  opium  increasing  up  to  15  grains  daily,  followed  by 
bromide  treatment,  has  been  advocated  by  Flechsig,  and  it 
has  been  tried  in  America.  We  have  given  it  an  exhaustive 
trial,  and  can  speak  of  it  as  one  worthy  of  consideration 
where  the  bromides  fail.  Other  drugs  too  numerous  to 
mention  must  here  be  passed  over  without  notice.  Epi- 
leptics who  have  undergone  surgical  treatment  for  causes 
other  than  epilepsy  enjoy  a  long  immunity  from  iits  after. 
Whitcombe  relates  a  case  of  recovery  after  many  years  of 
epilepsy  subsequent  to  a  surgical  operation.  I  now  come  to 
a  very  important  consideration,  viz.,  the  state  of  digestion 
and  the  condition  of  the  bowels.  The  initial  movement  of 
the  epileptic  discharge  does  not  always  take  place  in  the 
cortex  ;  peripheral  excitants  have  to  be  reckoned  with,  and 
of  these  the  irritations  of  indigestion  and  constipation  are 
most  important.  Herter  and  Smith,  who  have  made  re- 
searches on  this  subject  {New  York  Medical  Joimial,  1892), 
regard  putrefactive  processes  in  the  intestine  as  exciting 
causes  of  seizures.  The  diet  of  epileptics  should  consist  of 
food  easily  swallowed — butcher's  meat  chopped  or  minced — 
easy  of  digestion,  and  not  likely  to  give  rise  to  flatulence. 
Very  little  tobacco  should  be  allowed.  Stimulants  are 
contra-indicated.  The  bowels  should  be  regulated,  all  the 
more  because  epileptics,  if  allowed,  will  eat  over-much.  It  is 
well  to  warn  also  against  some  of  the  risks  run  by  epileptics  : 
(a)  Choking  during  a  fit.  Seizures  are  not  uncommon 
during  meals.  The  friends  and  attendants  should  be  fore- 
warned, and  instructed  what  to  do  in  such  cases.  They  will 
therefore  find  the  following  rules  serviceable :  (i)  Never 
allow  an  epileptic  to  have  food  that  may  easily  choke  him 
when  in  a  fit,  such  as  fish  with  bones,  tendon,  gristle,  and 
tough  pieces  of  butcher's  meat  ;  (2)  before  breathing  is  quite 
restored,  and  clonic  spasms  begin,  open  the  mouth  with  the 
handle  of  a  spoon,  and  shell  out  every  particle  of  food,  if 
necessary  getting  the  finger  well  back  through  the  fauces  to 
hook  out  anything  there.  (6)  Bathing.  This  is  a  risk  the 
forgetfulness  of  which  has  cost  epileptics  their  lives.  Epi- 
leptics should  never  bathe  alone. 


238  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

In  the  status  epilepticus,  when  there  is  often  imminent 
danger  to  life,  strong  cathartic  enemas  are  indicated. 
Antimony  may  be  useful,  but  blood-letting,  especially  vene- 
section, is  of  more  avail.  Dr.  Alexander  Robertson  has 
written  me  recommending  the  cold  douche  12  to  18  inches 
above  the  head,  especially  over  the  motor  area,  the  finger 
being  on  the  pulse  all  the  time.  I  have  not  yet  had  an 
opportunity  of  trying  this  treatment. 

{h)  Of  Insanity. — -If  you  reduce  the  fits,  you  reduce  a 
potent  exciting  cause  of  mental  disturbance ;  but  insanity 
having  once  broken  out,  or  when  there  is  danger  of  it  doing 
so,  what  is  best  to  be  done  ?  It  is  important  that  the  patient 
should  be  left  alone  after  fits,  and  not  moved  about,  if  at  all 
possible.  A  room  to  himself,  quietness,  and  time  to  sleep  off 
the  effects  of  the  fit,  are  of  great  importance.  A  good 
attendant  or  nurse  is  of  the  utmost  service  ;  if  they  are  active 
and  strong,  all  the  better,  but  tact  is  the  quality  most  required. 
Epileptics  do  not  take  kindly  to  strange  faces,  and  the  man 
who  is  most  familiar  to  the  patient,  and  who  has  gained  his 
confidence,  can  do  most  with  him,  and  is  most  likely  to  guide 
the  course  of  his  paroxysms  with  the  least  friction  possible. 

The  question  may  come  before  us  as  medical  men  at  any 
time.  Should  epileptics  marry  ?  This  question  will  be  re- 
garded from  two  points  of  view  :  First,  that  epilepsy  does 
not  necessarily  imply  insanity ;  second,  that,  notwithstanding 
this  reservation,  epilepsy  is  almost  invariably  an  ad  vitam 
neurosis  with  grave  risks.  Every  case  will  be  judged  on  its 
merits  ;  but,  in  the  words  of  Echeverria,  we  may  say  that  '  a 
serious  responsibility  rests  upon  any  physician  who  counsels 
the  marriage  of  epileptics,  both  as  regards  the  parties  them- 
selves and  the  future  of  the  offspring.' 

In  the  Middle  Ages  strong  views  prevailed  on  this  subject, 
and  the  same  authority  quotes  Boethius,  who  in  his  '  Croniklis 
of  Scotland  '  writes  of  the  custom  among  the  primitive  Scots 
in  these  words  :  '  He  that  was  trublit  with  the  fallin  evil,  or 
fallin  daft  or  wod,  or  havand  sic  infirmite  as  succeedis 
be  heritage  fra  the  fader  to  the  son,  was  geldit,  that  his 
infectit  blude  suld  spread  na  firther.  The  women  that  was 
fallin  lipper,  or  had  any  infestion  of  blude,  was  banist  fra  the 


EPILEPTIC  INSANITY  239 

company  of  men,  and  gif  she  consavit  barne  under  sic  in- 
firmity baith  she  and  her  barne  were  buryit  quik.' 

From  the  preceding  description  of  epileptic  insanity,  it 
must  at  least  be  evident  that  it  is  a  disease  of  many  mani- 
festations, even  in  the  same  individual,  and  several  carefully- 
prepared  clinical  studies  will  be  here  brought  forward,  so  as 
to  give  an  adequate  comprehension  of  the  many-sidedness  of 
the  disease. 

Clinical  Cases. 

/.  Epilepsy   appearing   after  Age  of  Twenty -three.     Marriage, 
Religious  Melancholia,  Violent  Outbursts,  Recovery. 

A.  B.,  set.  32,  mechanic ;  insane  a  few  days  before  ad- 
mission. '  Religious  melancholia ;  says  he  is  suffering  for  the 
sins  of  his  youth.  Mistakes  the  identity  of  the  person  with 
whom  he  converses.'  This  is  part  of  the  medical  statement 
received  on  his  admission  to  the  asylum.  Under  bromide 
and  general  treatment  he  soon  settled  down,  and  for  five 
months  was  almost  entirely  free  from  fits,  and  also  from 
excitement.  He  worked  in  the  garden  every  day,  made 
himself  useful  in  the  house  as  well,  and  was  in  all  respects 
a  most  intelligent,  rational,  agreeable  man.  It  was  decided 
to  discharge  him,  but,  in  order  to  run  no  serious  risk,  the 
bromide  was  discontinued  for  a  fortnight  in  order  to  judge  of 
his  nervous  stability  without  it.  A  week  later  he  had  fits  for 
three  nights  consecutively,  and  it  was  manifest  to  all,  after 
the  second  night,  that  a  storm  was  brewing.  The  first  sign 
was  a  breeze  of  words  on  religious  matters  with  some  other 
patients  in  the  same  dormitory.  From  less  to  more,  irri- 
tability, suspicion  and  excitement  gathered  volume  until  his 
violence  broke  out  on  some  unoffending  victim  and  he  was 
put  in  the  padded  room.  What  happened  afterwards  will 
come  out  in  the  following  report  of  a  clinical  demonstration 
to  medical  students,  after  he  had  recovered  from  the  attack. 

The  general  aspect  of  this  man  betokens  mental  depres- 
sion, partly  due  to  reaction  from  his  violent  excitement,  but 
in  great  measure  it  is  the  natural  disposition  of  the  man. 

Q.  Well,  Alick,  what  was  the  cause  of  your  coming  to  the 
asylum  ? 


240  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

A.  The  fits  ;  and  I  was  brooding  because  I  kept  the  know- 
ledge that  I  took  fits  from  my  wife  before  marriage. 

Q.  Did  your  wife  reproach  you  ? 

A.  No. 

Q.  Your  wife  found  it  out,  and  this  preyed  on  your  mind  ? 

A.  Yes. 

We  sent  him  out  to  work  after  he  settled  down  into 
rational  ways.  He  took  only  an  average  of  one  fit  a  month 
for  five  months,  and  then  we  decided  to  send  him  home. 

Q.  In  less  than  a  week  after  the  bromide  was  stopped,  how 
many  fits  had  you  ? 

A.   I  had  three  night-fits. 

B}^  some  night-fits  are  considered  of  more  serious  import 
than  day-fits ;  but  I  have  cases  that  never  take  day-fits,  and 
they  are  by  no  means  more  dangerous  than  others. 

Q.  After  the  first  two  you  made  a  complaint  to  me  about 
other  patients  talking  a  different  religion  from  yours.  Do 
you  remember  ? 

A.  Yes. 

While  in  the  padded  room  he  was  quite  beside  himself,  as 
madly  delirious  as  any  man  could  be,  utterly  oblivious  to 
all  appearance,  and  subject  to  terrifying  delusions  and  hallu- 
cinations. He  was  frantic  over  the  thought  that  the  whole 
asylum  was  in  flames,  and  he  was  to  be  the  victim,  and  then 
he  had  hallucinations. 

Q.  What  were  you  so  mad  at  the  attendants  for  ? 

A.  I  thought  they  were  mocking  me,  and  trying  to  make 
a  fool  of  me  and  my  religion. 

Q.  Do  you  remember  your  escape  from  the  padded  room  ? 

A.  Yes. 

Q.  Could  you  not  resist  the  impulse  ? 

A.  No.  I  was  carried  off  my  feet  with  a  wild  feeling 
inside  me.     I  had  to  go. 

The  attendant  foolishly  opened  the  door  of  the  padded 
room  to  see  how  Alick  was  getting  on,  instead  of  using  the 
little  window  in  the  door,  as  he  had  no  second  help  at  hand. 
Alick,  impelled  by  this  irresistible  wave  of  feeling  and  impulse, 
sprang  out  in  the  fury  of  his  excitement,  causing  the  atten- 
dant to  measure  his  length  on  the  floor.     One  leap  across  the 


EPILEPTIC  INSANITY  241 

corridor  and  through  a  window,  and  he  was  in  a  large 
enclosed  court  in  the  centre  of  which  is  a  fountain.  He 
tried  to  get  out  of  the  court  on  the  other  side  by  smashing 
with  utter  recklessness  square  yards  of  glass.  Failing,  how- 
ever, to  get  clear  away,  as  there  were  men  on  the  other  side, 
and  by  this  time  men  gathered  within  the  court,  he  leapt  on 
the  basin  of  the  fountain,  and  with  one  wrench  pulled  away 
the  metal  pipe  and  spray-producer,  and  thus,  his  eyes 
glaring  with  fury,  he  scowled  on  his  pursuers  and  defied 
them.  It  was  a  dangerous  position  of  affairs  for  all  con- 
cerned ;  but  the  head-attendant  ran  forward  suddenly  from 
an  unexpected  quarter  with  a  broom  and  dislodged  him  into 
the  soft  soil  below,  where  he  was  quickly  secured,  torn  and 
bleeding. 

When  his  bleeding  wounds  were  being  attended  to  by  one 
of  the  doctors,  he  was  very  wild  and  angry,  and  so  oblivious 
of  the  real  state  of  the  case  that  he  regarded  the  doctor,  who 
was  stitching  the  wound,  with  suspicion  (probably  because  he 
was  causing  him  pain),  as  the  real  cause  of  his  lacerated  hand. 

He  only  came  to  realize  that  the  doctor  was  not  at  all  a 
bad  fellow  after  several  days,  and  now  he  is  quite  free  from 
suspicion.  It  is  just  possible,  however,  that  in  another 
attack  of  the  kind  he  may  have  this  idea  regarding  the  doctor 
revived ;  for,  as  has  been  already  said,  there  is  a  tendency 
to  repetition  of  the  same  morbid  ideas  and  impulses  in  every 
recurring  attack  of  excitement. 

This  case  is  very  interesting  from  the  fact  that  he  remembers 
nearly  every  incident  of  the  attack,  for  this  is  quite  an  excep- 
tional experience.  Whether  it  is  due  to  the  very  exceptional 
circumstances,  'the  tragedy  of  the  fountain,'  as  we  call  it, 
and  to  the  fact  that  he  was  wounded  and  was  allowed  to 
bleed  freely,  is,  of  course,  mere  conjecture.  By  the  way,  it 
is  well  to  remember  that  it  is  a  good  thing  to  let  an  epileptic 
bleed  freely,  especially  if  he  is  full-blooded,  and  that  is 
generally  the  case. 

Q.  You  were  taking  bromide  when  you  were  at  home  ? 

A.  Yes,  but  not  regularly;  it  came  very  expensive,  especially 
when  I  was  out  of  work. 

Q.  At  what  age  did  the  first  fit  come  on  ? 

16 


242  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

A.  About  twenty-four  or  twenty-five. 

Q.  When  did  it  come  on  ? 

A.  At  night. 

Q.  Were  you  married  then  ? 

A.  No. 

Q.  Was  anyone  sleeping  with  you  at  the  time  ? 

A.  Yes,  an  apprentice. 

Q.  Was  he  wakened  by  the  fit  ? 

A.  Yes ;  he  made  me  understand  that  I  had  taken  a  fit. 

Q.   Has  there  been  insanity  in  your  family  ? 

A.  No. 

Q.  Did  your  father  take  drink  to  excess  ? 

A.  Yes. 

Q.  Did  your  mother  take  drink  to  excess  ? 

A.  Yes  ;  but  that  was  after  I  was  born. 

There  is  here  probably  a  history  of  potential  neurosis  in 
the  mother.  Alcoholic  Excess  in  one  or  both  parents  is  a 
frequent  precursor  of  Epilepsy  in  the  Family. 

Q.  How  often  did  you  take  fits  after  the  first  ? 

A.  Once  or  twice  a  month. 

Q.  How  soon  after  did  you  marry  ? 

A.  Five  years  after. 

Q.  Did  the  fits  become  more  frequent  after  marriage  ? 

A.  Yes. 

Q.  What  is  the  number  of  your  family  ? 

A.  One — three  and  a  half  years  old. 

Q.  Any  more  on  the  way  ? 

A.  I  think  so. 

Q.  No  miscarriages  ? 

A.  No. 
-     Q.  Do  you  know  when  a  fit  is  coming  on  ? 

A.  Yes  ;   by  a  feeling  of  fulness  in  the  stomach. 

Subsequent  Note. — This  man  was  discharged  seven  months 
later,  and  he  comes  regularly  to  see  me,  and  to  get  a  supply 
of  bromide.  He  is  earning  full  pay,  and  doing  very  well. 
He  is  of  melancholic  type ;  his  expression  is  still  rather 
subdued  and  sad,  but  he  has  brightened  up  a  little,  looks 
less  anaemic,  and  a  smile  comes  more  readily  to  his  face 
since  he  returned  to  the  bosom  of  his  family. 


EPILEPTIC  INSANITY  243 

//.  Case  of  Epilepsy  coining  on  after  Adolescence.  Due  to  Drink. 
Night  Fits,  Extreme  Irritability,  Epileptic  Mania,  Re- 
covery. 

G.  G.,  set.  37,  a  miner.  A  strong,  well-built  fellow,  bright 
and  intelligent,  slow  of  speech,  but  presenting  no  other 
nervous  symptoms.  His  history  is  as  follows,  obtained 
partly  from  himself  and  partly  from  his  brother. 

Father  was  a  drunkard.  G.  G.  was  much  addicted  to 
alcohol  himself.  He  was  naturally  quiet,  and  kept  by  him- 
self, but  when  in  drink  was  extremely  irritable  and  quarrel- 
some. The  epileptic  violence  broke  out  in  all  its  fury  at  the 
end  of  a  drinking  bout,  although  until  the  age  of  twenty- 
nine  he  had  never  been  known  to  have  taken  a  fit.  At  that 
time  he  had  a  long  spell  of  drinking,  and  one  day  went  to 
sleep  in  the  morning  in  the  grounds  of  a  public  park.  At 
mid-day  he  wakened,  and  thus  he  described  the  events  that 
followed  : 

'  The  sun  was  blazing  hot,  I  was  almost  blind,  had  an 
awful  headache,  went  to  my  lodgings  and  lay  on  the  bed, 
and  when  I  came  to  my  senses  that  night  they  told  me  I  had 
had  a  fit.     It  must  have  been  a  sunstroke.' 

The  sun  may  not  have  been  altogether  innocent  in  the 
matter  ;  but  G.  G.  might  more  truthfully  have  blamed  the 
drink,  even  if  this  implied  a  reflection  on  himself.  He  has 
since  taken  fits  at  long  intervals,  and  at  longer  intervals 
when  abstaining  from  drink.  He  takes  them  almost  invariably 
at  night,  knows  when  one  is  imminent  by  a  feeling  of  '  low- 
ness  of  spirits.'  He  goes  to  sleep,  wakens  in  an  hour,  and 
immediately  afterwards  the  fit  comes  on. 

The  chief  features  here  are  not  prolonged  excitement,  delu- 
sions, and  hallucinations,  but  simply  unreasonableness,  gun- 
powder irritability,  and  violence.  With  him  it  is  easier  to 
strike  than  to  speak.  He  does  not  lash  with  his  tongue,  but 
with  his  fist. 

This  case  is  still  under  observation,  although  he  has  been 
discharged,  for  he  comes  regularly  for  his  bromide  and 
laxative  pills.  Like  A.  B.,  he  knows  that  medicine  gives 
him  salvation,  and  he  has  been  working  regularly  for  some 

16 — 2 


244  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

months.  These  two  cases  illustrate  what  was  stated  at  the 
beginning  of  this  chapter,  that  epilepsy  which  makes  its 
appearance  late  does  not  reduce  the  mental  powers  to  any 
serious  extent  as  a  rule — at  least,  not  for  many  years,  unless 
the  fits  are  very  frequent,  and  it  is  unusual  for  them  to 
be  so. 

///.  Mental  integrity  was  fairly  good  all  his  life,  although 
Epilepsy  came  on  in  boyhood;  hut  it  was  more  Jacksonian  in 
character.  The  fits  were  rare.  If  consciousness  was  at  times 
abolished,  it  was  a  mere  passing  cloud,  and  a  cranial  injury  during 
boyhood,  with  well-defined  cerebral  lesion,  was  probably  the  exciting 
cause. 

J.  R.,  set.  27  on  admission;  tall,  broad-shouldered,  well 
built.  His  mother  and  brother  are  epileptic,  but  neither 
has  been  insane,  although  the  mother  is  distinctly  peculiar, 
and  has  the  mental  habit  of  the  epileptic  quite  evident. 
J.  R.  when  a  boy  was  kicked  on  the  head  by  a  horse. 
Trephining  was  necessary,  and  over  the  right  parieto-frontal 
region  there  is  a  scalp  depression  the  size  of  half  a  crown. 
The  leg  and  arm  of  the  left  side  are  paralyzed — the  arm 
entirely,  the  leg  partially.  This  condition  of  paralysis  has 
been  stationary  since  the  accident. 

Mimicry  was  a  pronounced  feature  in  this  case,  and  he 
would  probably  never  have  been  suspected  of  epilepsy  except 
for  the  family  history.  He,  having  seen  his  mother  and 
brother  in  fits,  must  have  had  the  memory  of  the  various 
contortions  burned  into  his  brain  from  his  youth  upward. 
Be  that  as  it  may,  after  his  admission  to  the  asylum  he 
feigned  epilepsy  with  the  skill  of  a  conjurer.  The  first 
suspicion  that  he  was  feigning  arose  from  the  fact  that  as 
time  went  on  he  played  too  many  variations  on  his  theme, 
and  his  attacks  of  nystagmus,  which  were  as  perfect  imita- 
tions as  could  be  desired,  were  cut  short  by  the  brusque 
diagnosis  of  a  doctor  who  saw  him  for  the  first  time,  and 
suggested  that  he  was  a  sham. 

He  certainly  took  very  few  epileptic  fits  afterwards,  but  they 
were  usually  real,  I  have  no  doubt,  and  when  he  did,  for  love 
of  sympathy,  present  a  sham  one,  he  was  promptly  brought 


EPILEPTIC  INSANITY  245 

to  book  over  the  matter.  The  chief  feature  in  his  case  was 
the  religious  strain  that  ran  through  his  whole  character, 
and  though  he  might  at  times  be  excited  in  his  states  of 
religious  exaltation,  he  was  never  profane  or  violent.  He 
may  have  swerved  from  the  truth,  for  in  his  '  raised  '  con- 
dition the  epileptic  has  no  moral  regard  for  it  ;  but  that  is 
the  worst  that  can  be  said  of  him. 

IV.  Case  of  Yotmg  Man  with  Hereditary  History  of  Paralysis — 
Father  died  of  it — and  Family  Nervousness,  Masturbation, 
Melancholia  —  replaced  hy  Exaltation ;  two  years  later 
Epilepsy,  Sneezing  Fits. 

D.  D.,  get.  25.  The  attack  began  with  religious  depres- 
sion which  unmanned  him  so  that  he  would  spring  suddenly 
from  his  seat,  cry  out  wildly  that  his  soul  was  lost,  dash  his 
hands  on  the  table,  tear  his  hair,  and  lose  his  self-control 
completely.  Was  addicted  to  masturbation.  After  a  year 
the  symptoms  changed :  there  was  mild  exaltation,  but  not 
altogether  of  unreasonable  character.  He  fancied  that  his 
life  was  a  failure  because  he  had  not  entered  a  sphere  of 
work  suited  to  his  abilities — that  his  work  should  have  been 
mental,  and  not  physical.  He  began  afterwards  to  think 
his  talent  not  much  inferior  to  Carlyle's. 

A  year  later  he  was  less  placid  and  agreeable  in  character, 
showed  signs  of  irritability  and  impulsiveness,  and  on  one 
occasion  raised  a  spade  to  strike  an  attendant.  Four 
months  later  he  was  seized  with  an  epileptic  fit  an  hour 
after  dinner.  Although  he  lived  for  over  three  years  there- 
after, he  had  not  another,  so  far  as  known,  unless  we  regard 
as  of  the  nature  of  epilepsy  sneezing  attacks  which  troubled 
him,  always  at  night,  for  over  two  years,  leaving  him  ex- 
tremely pale  and  nervous  afterwards,  and  on  one  occasion, 
with  intervals  between,  lasting  from  10  p.m.  to  12  p.m.  The 
following  is  a  copy  of  letter  written  to  his  mother  : 

'  Dear  Mother, 

'  D.  D.  is  a  self-  abuser  by  nature.  The  asylum 
attendants  have  erected  a  new  lavatory ;  it  seems  to  be  well 
patronized.     I  was  the  first  patient  that  ever  sat  in  it.     The 


246  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

attendants  have  been  very  kind  to  me  since  I  came  here. 
I  am  sorry  to  hear  of  your  spitting  blood,  but  I  hope  God 
will  cure  you  soon.  I  have  been  in  the  habit  deserter  of 
cause,  do  you  have  to  blame  your  prodigal  son  if  I  may 
assume  to  be  that.  I  may  say  this  band  of  my  adoption, 
forgive  an}^  wrong  that  I  have  done  towards  you  freely  as 
king  forgiven,  hoping  you  will  meet  on  better  times.' 

The  last  half  of  the  letter  shows  failure  in  expression  and 
incoherence,  and  as  his  disease  progressed  this  became  more 
and  more  noticeable.  He  frequently  had  sick  turns  in  the 
morning,  with  vomiting  and  slight  convulsive  movements 
of  the  legs,  but  no  unconsciousness.  Probably  all  these 
sj^mptoms  were  due  to  masturbation.  He  became  more  and 
more  violent  as  time  went  on,  and  died  of  lung  disease  after 
five  years'  residence  in  the  asylum. 

V.  Case  of  Epileptic  Insanity  following  Intemperance  ;  Periods  of 
Stupor  and  Automatism  ;  Hypochondriac,  Violent. 

A.  M.,  set.  27 ;  not  his  first  attack  ;  has  been  intemperate  ; 
suspicious  of  his  wife's  fidelity  ;  hallucinations  of  hearing  and 
sight.  When  he  has  a  series  of  fits  he  does  not  wake  com- 
pletely out  of  the  post-epileptic  stupor  for  hours ;  he  remains 
for  some  time  in  a  dazed,  somnambulistic  state,  and  he  goes 
about  in  it  automatically  collecting  pins,  bits  of  wire,  thread, 
or  anything  he  can  hoard.  Sometimes,  however,  after  a  fit, 
the  eyes  are  fixed,  the  pupils  dilated,  the  face  pale,  soon 
followed  by  a  flush  over  the  face  ;  he  then  perspires  freely, 
the  pupils  get  smaller,  and  he  wakes  up.  In  the  former  state 
his  bowels  have  often  to  be  relieved  by  enemata,  and  his 
urine  to  be  drawn  off.  He  frequently,  after  fits,  makes  com- 
•  plaints  of  ill  usage,  but  often  his  complaints  are  more  hypo- 
chondriacal in  character,  such  as  that  his  sight  is  gone,  that 
his  testicles  are  diseased,  etc.  He  is  very  shaky  and  tremulous 
even  when  free  from  fits,  also  quarrelsome  and  treacherous 
even  with  his  fellow-epileptics. 


EPILEPTIC  INSANITY  247 


Female  Cases. 

VI .  Depression,  Stiicidal  A  ttempts,  Hysteria,  Eroticism, 
Dysmenorrhcea. 

R.  B.,  set.  26 ;  second  attack  ;  was  in  asylum  two  years 
previous.  Previous  to  the  first  she  tried  to  cut  her  throat. 
Several  superficial  cicatrices  are  still  in  evidence  below  the 
thyroid  cartilage.  The  day  before  her  second  admission  to  the 
asylum  she  tried  to  strangle  herself  with  a  garter,  and  secreted 
scissors  '  in  her  breast.'  Fits  come  on  usually  the  night 
before  menstruation,  which  is  painful,  and  she  gets  depressed 
afterwards.  Such  is  the  history.  The  asylum  report  is  brief : 
'  Slow,  hesitating,  wailing  speech,  scared  look,  wants  sym- 
pathy, beseeching  expression  .  .  .  had  a  fit  of  grand  mal, 
recovered  complete  consciousness  in  fifteen  minutes  after  .  .  . 
next  day  had  two  fits  in  the  early  morning  and  three  in  the 
afternoon  ;  thereafter  she  was  strange  and  absent  in  expres- 
sion, stupid,  and  erotic.  Usually  mental  obscuration  before 
fits,  and  afterwards  brighter.'  She  made  no  suicidal  attempts 
in  the  asylum,  where  she  died  of  lung  disease. 

VII.  Mental  Depression,  Running  Fits,  Strange  Visceral 
Illusions,  Aphasia,  Recovery. 

Mrs.  W.  T.,  aet.  46  ;  '  not  first  attack  ;  cries  and  wrings 
her  hands ;  will  not  answer  questions  ;  no  history  obtained. 
There  is  the  suggestion  of  a  murmur  in  the  mitral  and 
tricuspid  areas.  Pulse  96.  She  is  cyanotic  and  puffy  round 
the  eyes.  Seems  tender  on  pressure  above  the  umbilicus.' 
Four  days  later,  eyes  bright,  congested,  wobbles  her  head,  and 
puts  her  hands  on  vertex  as  if  in  pain.  Next  day  she  had  a  fit 
during  the  medical  visit.  She  ran  round  a  table  in  the  ward 
three  times,  then  fell  on  her  face  and  became  convulsed,  but 
not  severely.  The  pulse  was  136,  ten  minutes  later  108, 
and  the  breathing  became  stertorous.  Next  day  she  was 
very  excited  and  violent,  struck  and  kicked  anyone  and 
everyone,  tore  her  clothes,  said  there  was  a  tin  box  in  her 
stomach,  and  complained  of  it  hurting  her ;  bowels  were 
loaded.     Castor-oil  was  given  without  effect,  and  then  croton 


248  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

oil  with  a  better  result.  Very  excited  and  sleepless.  Did 
not  seem  able  to  speak  at  times,  and  when  she  got  her 
voice  explained  there  was  a  piece  of  glass  in  her  throat. 
She  wanted  to  swallow  buttons  to  push  it  down.  Her  next 
sensation  of  the  tin  box  was  below  the  umbilicus,  and  after 
another  fit  it  disappeared  altogether.  Later,  speech  was 
very  difficult  to  comprehend  after  an  attack  of  excitement, 
the  words  being  so  imperfectly  formed.  Under  bromide  and 
general  treatment  the  fits  subsided,  the  mental  excitement 
disappeared,  and  she  was  discharged  recovered  in  six  months. 
The  last  entry  in  the  case-book  is  as  follows  :  '  Has  had 
no  return  of  epilepsy.  Is  bright,  intelligent,  active,  and 
industrious  ;  has  no  recollection  of  the  events  of  her  illness, 
only  of  being  in  a  trance  when  she  was  brought  to  the 
asylum.' 

VIII.   Weak-minded  Epileptic ;  Pecidiar  Running  Fits,  not 
always  in  the  same  order. 

C.  M.,  set.  ig  ;  rather  weak-minded.  Would  burn  or  hide 
things.  Fits  more  frequent  at  night  than  during  the  day, 
usually  at  the  beginning  of,  or  during  menstruation,  and  often 
of  petit  mal  form.  Frequently  runs,  i.e.,  runs  with  her  eyes 
fixed  straight  in  front,  and  with  an  expression  like  that  of  a 
sleep-walker,  blank  and  visionless.  Often  runs  immediately 
she  recovers  from  a  fit,  and  sometimes  before  it.  Thus  she 
escaped  from  a  walking-party,  not  knowing  what  she  was 
doing  nor  where  she  was  going,  and  when  she  was  brought 
back  had  a  true  epileptic  seizure.  A  fourth  variation  was  a 
run  followed  by  stupor  and  then  recovery,  without  convulsion 
at  all.     She  was  vindictive  rather  than  impulsive. 

IX.  Extremely  High-strung,  Sensation  Acute,  Intense  Irrita- 
bility, Unprincipled  and  Vindictive,  Hallucinations  of  Hear- 
ing, Delusions  of  Identity. 

M.  N.,  aet.  35.  Has  been  epileptic  for  at  least  nine  years, 
probably  longer.  She  is  quarrelsome  and  officious,  wants  a 
lot  of  attention,  and  thinks  herself  neglected  in  the  matter  of 
treatment.  Complains  frequently  of  a  weight  on  the  top  of 
her  head.     One  day  in  a  fit  she  was  conscious  of  being  laid  on 


EPILEPTIC  INSANITY  249 

the  floor,  but  could  not  speak.  Her  mental  irritability  is 
worse  at  menstrual  periods.  Theoretically  she  knows  right 
from  wrong,  but  in  practice,  when  her  own  actions  are  in 
question,  right  is  wrong,  and  vice  versa.  She  is  vindictive, 
schemes  for  revenge,  and  so  differs  from  the  epileptic  who  is 
moved  by  mere  blind  impulse.  She  will  watch  her  chance 
to  hurt  people  she  hates.  After  a  struggle  she  lies  perfectly 
still  as  if  in  a  fit,  but  is  quite  conscious.  She  has  delusions 
of  identity  after  fits.  The  fits  are  frequently  of  the  petit  mal 
type.  She  is  extremely  hypersesthetic.  A  sudden  sound  or 
unexpected  voice  makes  her  start  violently.  One  day,  dis- 
turbed by  a  noisy  patient  beside  her  at  dinner,  she  lifted  a 
plate  and  broke  it  over  the  noisy  patient's  head.  She  has 
slight  fits  of  unconsciousness  or  vertigo,  or  blindness  for  the 
moment,  and  seeing  things  double. 

X.  Ilhisions  during  Menstruation ;  Irritable,   Violent,  Childish, 

and  Sulky. 

M.  K.,  set.  26.  Temperature  on  admission  100''  after  a 
series  of  fits  and  while  in  a  state  of  maniacal  excitement. 
Convulsions  general.  Irritable  before  and  after  menstrua- 
tion, a  most  dangerous  epileptic.  Has  a  very  pronounced 
feeling  of  being  swollen  during  menstruation,  and  says  she 
is  with  child.  Babyish.  Easily  misled  by  others.  Aider 
and  abettor  of  mutiny.  Complains  of  headache  and  not 
being  able  to  retain  her  urine.  She  is  very  sulky  in  her  bad 
moods,  and  is  under  the  delusion  that  the  house  belongs  to 
her,  and  no  one  else  has  a  right  to  be'  here. 


The  following  case  is  very  instructive  because  of  its 
multiple  character,  and  the  concurrence  of  A  Icoholic  Excess, 
Syphilis,  Epilepsy,  Delirium  Tremens,  and  Insanity. 

XI.  Has  been  a  hard  drinker  for  many  years.  Used  to 
have  bad  headaches  after  bouts  of  drinking,  but  now  feels 
giddiness  instead.  Five  years  previous  to  admission  had  a 
true  syphilitic  chancre,  followed  by  mild  secondary  symptoms. 
In  less  than  a  year  epileptic  fits  came  on,  and  he  was  treated 
at  the  Western  Infirmary,  Glasgow,  by  Dr.    Hinshelwood, 


250  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

who  kindly  furnished  me  with  notes  of  the  case.  The  fits 
came  on  chiefly  at  night,  were  preceded  by  an  aura  in  the  left 
arm,  pain  in  the  neck  and  behind  the  ears,  occasionally  also 
in  the  left  shoulder.  There  was  loss  of  memory  and  speech 
disturbance. 

As  long  as  he  was  drinking  he  was  not  in  the  least  troubled 
with  fits,  but  as  soon  as  he  stopped  drinking  the  fits  came 
on.  He  was  sent  to  an  asylum  after  this  with  delirium 
tremens,  but  was  discharged  in  a  few  weeks. 

A  second  attack  came  on  later,  when  we  obtained  a 
further  history.  He  was  not  a  man  who  went  to  church 
except  as  a  matter  of  form  ;  but  when  he  became  epileptic, 
a  religious  change  came  over  him,  and  he  enjoyed  going  to 
church,  and  developed  the  typical  religiosity  of  the  epileptic. 

The  speech  was  distinctly  affected,  thick  and  tremulous. 
Aphasia  of  a  limited  character  was  noticed  after  epilepsy 
supervened,  and  cephalic  sensations  of  a  very  distressing 
character  disturbed  him,  especially  at  night,  as  if  '  all  the 
bees  in  the  country  '  were  buzzing  in  his  head,  and  many 
other  strange  sensations,  often  one-sided,  but  not  always  so. 
After  fits  these  annoyances  disappeared  for  a  time. 

His  mental  character  had  two  sides  :  (i)  when  free  from 
fits,  agreeable  and  pleasant ;  (2)  after  fits,  suspicious — thought 
the  sphygmograph  was  fixed  on  his  wrist  to  cause  his  un- 
pleasant sensations.  Was  also  suspicious  regarding  the 
medicine  prescribed.  Epileptic  paroxysms  of  excitement 
and  irritability,  with  hallucinations  of  sight,  were  sure  to 
break  out  at  these  times.  He  declared  that  he  saw  electricity 
working  under  his  bed,  and  then  playing  over  his  body. 

Under  appropriate  treatment — anti-syphilitic,  combined 
with  enforced  total  abstinence — the  fits  became  fewer,  and 
he  was  discharged  recovered  after  three  months'  residence  in 
the  asylum. 


CHAPTER  XIII. 

EVOLUTIONAL  AND  DISSOLUTION AL  TYPES. 

Insanity  of  puberty  in  relation  to  heredity — The  influences  of  heredity  in 
early  life — Insanity  of  puberty  and  adolescence  expressed  in  different 
degrees  according  to  their  respective  epochs — Characters  ill  formed 
—  Mobile  disposition — Cycles  of  change,  different  types — Hysterical 
insanity — Climacteric  in  the  male  and  female— Larger  proportion  of 
females — Different  types  of  mental  disease— Senile  insanity  of  three 
kinds  :  (i)  functional,  (2)  cases  overlapping  from  functional  to  organic, 
(3)  senile  dementia  due  to  organic  brain  degeneration — Clinical  illus- 
trations under  these  several  heads. 

The  insanities  occurring  at  the  periods  of  puberty  and 
adolescence — the  insanities  of  mental  evolution — are  the 
result  of  a  bad  start  in  mental  life,  or  untoward  circum- 
stances in  the  nervous  or  mental  development  of  childhood. 
Patients  of  this  class  are  sometimes  regarded  as  belonging 
to  the  order  of  degenerates,  and  in  certainly  not  a  few  cases 
the  mental  character  is  so  ill  formed,  the  moral  and  emotional 
nature  so  eccentric,  and  dissolution  so  premature  and  com- 
plete, that  these  abortive  men  and  women  are  truly  degenerates. 
Heredity  is  an  important  feature  in  the  production  of  these 
types  of  insanity,  and  the  degree  of  this  influence  is  mani- 
fested according  to  the  age  when  mentab  degeneration  or 
insanity  appears.  An  idiot  is  the  most  extreme  victim  of 
heredity.  Later  hereditary  effects  are  seen  in  the  first  years 
of  childhood,  and  in  the  nervous  incidents  of  youth,  in 
retarded  or  eccentric  mental  development  or  lop-sided  pre- 
cocity. The  manifestations  of  heredity  in  early  life  seem  to 
affect  the  motor  system  more  than  the  sensory,  and  the 
nervous  system  more  than  the  mind.  The  reason  probably 
is  that  the  motor  system  is  later  in  its  development  than  the 
sensory,  and  that  mental  evolution  being  the  least  advanced, 


252  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

and  so  fugitive  in  its  early  features,  there  is  little  for  the 
insane  process  to  lay  hold  of  or  play  havoc  with.  Be  that 
as  it  may,  it  is  certainly  true  that  motor  disorders,  motor 
excitement,  and  unrest  are  most  in  evidence  in  the  morbid 
development  of  puberty. 

To  resume,  then  :  the  most  potent  evidence  of  heredity  is 
seen  during  childhood  and  early  life,  in  idiocy  and  imbecility, 
in  various  motor  disorders  of  the  nervous  system  ;  and  at 
puberty,  in  the  various  disorders  of  these  systems  being  ex- 
aggerated, and  combined  with  more  or  less  mental  instability. 

Insanity  of  Puberty. 

The  insanity  of  pubert}^  cannot  be  expected  to  express 
itself  in  the  same  way  as  that  of  more  mature  age.  A  boy 
or  girl  of  thirteen  or  fourteen  is  unformed  mentally  as  well 
as  physically.  The  mind  is  still  in  a  state  of  transition,  and 
the  mental  character  is  plastic  and  undergoing  new  forma- 
tions. His  life  is  largely  a  selfish  life,  with  a  new  egotism 
appearing  as  the  result  of  sexual  evolution.  Sentiment  and 
ambition,  without  intellectual  check  or  the  pruning  of  ex- 
perience, are  dominant  in  his  life.  The  insane  range  of  this 
epoch  is  still  more  unsystematized,  mobile,  variable,  and 
erratic.  The  mere  fact  that  insanity  appears  so  early — and 
it  is  rare  at  this  time — shows  lack  of  stamina  and  develop- 
mental energy  which  must  be  the  result  of  inherent  weakness. 

The  period  of  puberty  is  in  general  practice  found  to  be 
ushered  in  by  nervous  crises  in  a  certain  proportion  of  cases 
which  do  not  become  insane.  These  may  take  the  form  of 
hysteria,  'chorea,  or  epilepsy,  and  there  is  usually  anaemia 
in  attendance  also.  These  nervous  departures  from  normal 
indicate  of  themselves  hereditary  weakness  in  many  cases,  and 
they  are  links  connecting  healthy  puberty  on  the  one  hand 
with  insane  puberty  on  the  other.  In  some  cases  they  are 
but  the  prodromata  of  the  insanity  of  puberty  itself. 

The  mental  symptoms  arernore  objective  than  subjective. 
These  young  patients  are  very  much  in  evidence ;  but  here, 
as  in  the  insanity  of  adolescence  to  be  afterwards  described, 
the  mobility  of  the  mental  character,  the  uncertainties  of  its 
development,  are  the  most  striking  features.     The  only  thing 


EVOLUTIONAL  AND  DISSOLUTIONAL  TYPES         253 


that  is  impossible  in  the  course  of  the  disease  is  consistent 
purpose  and  conduct.  The  same  patient  will  pass  rapidly 
through  phases  of  maniacal  excitement,  melancholia  with 
suicidal  impulse  and  stupor,  and  again  break  out  into  mania. 
In  the  maniacal  state  the  patient  may  be  very  much  exalted ; 
his  day-dreams  are  realities ;  he  is  acting,  to  all  appearance 
with  the  unconsciousness  of  a  true  actor,  what  he  is  not — a 
prince,  a  duke,  a  general,  something  heroic ;  and  as  he 
strides  about  and  swaggers  it  is  so  amusing  and  absurd 
that  one  wonders  whether  the  boy  is  consciously  '  playing 
at  soldiers '  or  really  believing  what  he  says.  The  muscular 
activity  is  sometimes  incessant.  It  is  a  chorea  of  locomo- 
tion and  bustling  officiousness.  The  boy  is  full  of  himself; 
his  egotism  is  supreme  and  all-important.  He  puts  on  airs, 
does  his  best  to  look  and  act  like  a  man,  and  is  often 
bold,  rude,  and  offensive  to  his  elders  and  superiors.  (This, 
by  the  way,  is  an  exaggeration  of  the  character  of  many  boys 
at  puberty.)  His  day-dreams  have  become  facts,  and  he 
speculates  and  undertakes  liabilities  as  if  he  were  a  grown 
man.  The  case  is  one  of  precocious  manhood,  and  one  little 
telegraph-boy  was  so  inflated  with  his  belief  in  his  business 
capacity  that  he  tried  to  negotiate  for  the  lease  of  a  large 
jeweller's  establishment  which  he  proposed  to  run  forthwith. 
The  resemblance  of  the  mental  and  motor  symptoms  of 
insanity  of  puberty,  and  the  stage  of  maniacal  exaltation  of 
general  paralysis,  is  very  striking.  It  is  a  transient  delirium 
followed  by  melancholia  or  stupor. 

Another  type  is  more  hysterical  in  character,  and  is  seen 
especially  in  girls,  who  are  really  more  precocious  and  self- 
conscious  for  their  age  than  boys.  It  is  also  maniacal, 
irrepressible,  mischievous,  playful,  and  eager  of  personal 
notice.  It  may  affect  melancholia,  and  even  be  attended 
with  suicidal  threats.  Some  such  cases  talk  of  suicide  with 
an  air  of  serious  purpose,  and  require  to  be  carefully  watched 
and  strictly  disciplined.  While  many  hysterical  cases  talk 
of  suicide  without  really  meaning  it,  a  few  are  quite  serious, 
and  their  impulses  are  probably  associated  in  many  cases 
with  masturbation.  The  hysterical  element  is  sometimes 
seen  in  boys  as  well  as  girls.     Up  to  this  time  the  sexes  are 


254  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

little  removed  from  each  other  mentally,  and  the  childish, 
irrepressible  character  is  still  in  evidence.  As  a  rule,  hysteria 
affects  girls  however.  One  girl  kept  shouting,  'Oh,  my 
mother!  Oh,  my  sister !  Ask  the  devil!'  and  then  began 
to  sob  loudly  and  hysterically. 

Hallucinations  of  sight  are  not  infrequent ;  but  the  moral 
sense  is  so  deficient,  and  these  patients  are  sometimes  such 
accomplished  liars,  that  their  statements  have  to  be  carefully 
sifted  to  be  sure  that  the  hallucinations  are  not  vain  boasting. 
Delusions  of  identity  are  sometimes  observed. 

Masturbation  is  frequently  a  symptom  with  boys,  being 
in  this  respect  another  phase  of  the  evil  inheritance  of  a 
degenerate  nervous  system.  It  is  not  seen  so  frequently  in 
girls ;  but  menstruation  in  their  case,  acting  on  a  susceptible 
brain,  is  a  disturbing  factor  of  some  gravity.  It  is  usually 
difficult  and  irregular  ;  but  does  not  seem  painful,  while  the 
patient  is  excited  owing  to  her  oblivion  of  ordinary  sensa- 
tions. When  she  does  complain  of  it,  the  symptom  is  a 
good  one  for  her  mental  condition. 

Prognosis. 

The  prognosis  is  good.  I  have  rarely  seen  a  case  that  did 
not  recover  ;  but  unfortunately  relapse  is  almost  certain  in 
the  adolescent  stage,  and  then  the  chances  of  recovery  are 
not  so  good.  It  must  be  remembered,  in  considering  the 
prognosis,  that  a  class  of  cases  not  far  removed  from  the 
imbecile  class  become  insane  at  puberty  or  at  adolescence. 
Whilst  tolerated  outside  so  long  as  they  are  amenable  to 
society's  rules,  when  excitement  breaks  out  they  are  sent  to 
asylums,  and  often  discharged  after  the  excitement  has  sub- 
sided. These  are  not  true  recoveries ;  they  have  merely 
returned   to  the  quiescent  status  quo  of  their  weak-minded 

condition. 

Treatment. 

This  must  be  determined  by  the  state  of  the  case,  but  in 
all  good  moral  discipline  is  required.  Medical  treatment 
can  do  much,  and  the  indications  for  treatment  are  :  anaemia 
(iron  and  malt  extract  with  cod-liver-oil)  ;  motor  disorders 
(arsenic  and  bromide)  ;   want  of  tone,  loss  of  weight,  and 


EVOLUTIONAL  AND  DISSOLUTIONAL  TYPES         255 

sleeplessness  (the  open  air  as  much  as  possible,  milk  diet, 
eggs,  fish  and  white  meat,  and  tepid  baths  gradually  altered 
from  day  to  day  to  cold  baths,  with  friction  and  active 
exercise  afterwards). 

Insanity  of  Adolescence, 

The  period  of  adolescence  is  an  epoch  well  advanced  from 
puberty,  a  stage  in  which  the  mind  is  able  to  express  itself 
more  freely,  and  to  draw  from  its  more  mature  resources,  so 
as  to  feed  insane  feelings  and  suggestions  with  extravagant 
imaginations,  and  widen  the  range  of  insane  expression. 
While  still  a  stage  short  of  maturity,  it  has  its  own  charac- 
teristic features ;  for  it  is  the  age  of  ripening  manhood, 
pregnant  with  emotions  and  love-dreams  and  lofty  aspira- 
tions. The  education  of  the  school  is  finished,  and  the 
memory  is  charged  with  poetic  allusions  and  reminiscences 
of  the  traditions  and  history  of  the  world.  If  self-control 
be  lost,  and  excitement  should  break  out,  the  torrents  of 
language,  the  dramatic  extravagances  of  conduct  that  are 
possible,  will  give  a  presentment  of  the  disease  more 
systematized  and  more  prolonged  than  is  seen  in  the 
insanity  of  puberty. 

The  same  defect,  want  of  stamina  and  staying  power,  is 
here  noticed  also,  though  in  a  less  degree.  The  purpose 
and  conduct  are  more  consistent,  because  of  the  later  and 
more  mature  stage  of  development  reached ;  but  the  evidences 
are  still  uncertain — mobile,  erratic,  and  very  different  from 
what  are  observed  in  chronic  delusional  insanity.  In  the 
latter  you  cannot  help  still  respecting  the  strength  of  the 
man's  character.  In  the  former  you  know  him  to  be  in 
many  cases  a  weakling,  and  this  is  most  apparent  in  the  fact 
that  he  relapses  again  and  again  before  recovery  is  finally 
assured,  if  ever  it  be. 

It  ought  at  this  stage  to  be  recognised  that  three  classes 
come  under  the  category  of  insanity  of  adolescence  :  (a)  the 
naturally  feeble-minded,  who  are  subject  to  crises  of  excite- 
ment ;  (6)  the  masturbators,  who  are  really  degenerates ; 
(c)  the  primary  idiopathic  type,  with  well-defined  cause,  and 
more  consistent  onset  and  course,  less  tendency  to  relapse, 


2  56  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

and  more  hope  of  recovery.  These  three  are  not  sharply 
defined  from  each  other,  but  they  serve  as  landmarks. 

This  disease  may  be  maniacal,  melancholic,  stuporose,  or 
pass  and  repass  through  all  three  stages.  No  precise  type 
of  mania  or  melancholia  can  be  described ;  but  certain 
general  features,  culled  from  a  large  collection  of  case-book 
records,  will  be  here  arranged  and  described. 

Sentiment  and  ambition  enter  largely  into  the  mental 
equation  at  this  epoch.  It  is  well  to  remember  this  when 
trying  to  piece  together  with  a  view  to  coherence  the 
ravings,  the  strange  conduct  and  manner,  of  the  patient. 
If  you  consider  for  a  moment  that  this  youth  started  life 
full  of  hope  and  promise,  that  to  his  parents  and  himself  he 
seemed  potentially  gifted,  and  that  he  has  failed,  perhaps 
from  too  great  optimism,  from  want  of  judicious  pruning, 
or  from  being  allowed  to  burn  the  candle  at  both  ends,  you 
will  not  be  surprised  to  learn  that  many  adolescents  become 
depressed  and  break  down  because  they  have  aimed  too 
high,  and  failed  to  grasp  anything  at  all. 

The  unrealized  ideals  of  the  adolescent  often  lead  to 
despondency,  and  suicidal  acts  sometimes  result  from  want 
of  moral  courage,  or  they  may  result  from  masturbation. 
One  young  fellow  of  promise,  but  hampered  by  the  vice  of 
masturbation,  lost  heart  from  mental  failure  to  work  up  to  a 
given  standard,  and  tried  to  blow  himself  up  with  gunpowder. 
Another  too  ambitious  young  fellow — not  a  masturbator — 
for  a  like  reason  cut  his  throat. 

In  its  maniacal  form,  adolescent  insanity  is  often  accom- 
panied with  delusions  of  an  exalted  character.  These  are 
often  limited  in  their  number,  and  by  no  means  always  so 
foolish  or  extravagant  as  those  of  the  general  paralytic, 
whose  exaltation  is  avaricious.  One  young  fellow  regarded 
himself  as  next  to  Christ,  and  surrounded  by  angels  ;  another 
assumed  the  role  of  a  Palestine  nobleman  ;  while  a  third 
described  himself  as  'John  V.  Vandeleur,'  who  had  just 
come  to  his  castle  (the  asylum),  refused  the  ordinary  diet, 
calling  for  wine,  champagne,  and  comestibles  suited  to 
his  rank.  While  these  are  conceivable  insane  aspirations, 
others  are  more  unintelligible,  feebly  explained,  and  foolishly 


EVOLUTIONAL  AND  DISSOLUTIONAL  TYPES         257 

justified.  One  young  lady  regards  herself  as  the  daughter 
of  the  Prince  of  Wales,  but  adds  that  the  matron  of  an 
asylum  is  her  mother.  She  carries  herself  with  great  dignity  ; 
but  is  lazy,  unwieldy,  and  gluttonous. 

The  weakness  of  intellect  which  may  characterise  insanity 
at  this  period  is  evident  in  absence  of  the  power  of  adequate 
expression.  Even  very  simple  statements  are  in  some  cases 
loosely  and  irrelevantly  put  together.  The  ambition  is  mani- 
fest ;  but  beyond  the  consciousness  that  an  ideal  is  aimed  at, 
there  is  no  evidence  of  mental  grip  or  reasoning  power. 
There  is  grasping  at  an  idea  without  real  comprehension  of 
the  aim,  and  how  to  betoken  the  result. 

Amorous  ideas  frequently  take  possession  of  the  mind, 
and  sometimes  find  expression  in  poetic  effusions — an  exag- 
geration of  normal  adolescence.  Religious  emotionalism,  a 
frothy  effervescence,  may  be  a  passing  phase  of  the  mental 
excitement.  Irritability  and  violence  are  not  uncommon  ; 
for  this  is  the  age  of  impulsiveness,  and  it  often  arises  from 
opposition  which  the  patient  will  not  brook,  and  not  infre- 
quently from  the  assertion  of  parental  authority,  which  the 
patient,  in  his  assumption  of  another  and  more  exalted 
personality,  will  not  submit  to.  Therefore  we  find  parents 
assaulted,  and  their  visits  declined  with  haughty  mien  and 
contemptuous  language. 

The  excitement  of  the  female  adolescent  is  one  of  high- 
flown  sentiment,  of  visionary  character  fostered  by  halluci- 
nations of  sight ;  or  it  may  be  erotic,  impulsive,  violent,  and 
even  hysterical.  While  the  sexual  exaltation  in  the  male 
shows  itself  usually  in  the  practice  of  masturbation  in  secret 
places,  and  occasionally,  though  more  rarely,  in  amorous 
advances  to  the  other  sex,  in.  the  female,  erotic  vanity  and 
solicitation,  even  exposure  of  the  person,  are  very  frequent, 
especially  when  the  symptoms  are  hysterical  in  their  extra- 
vagance. 

Hallucinations  of  sight  and  hearing  are  common.  One 
man  sees  visions,  another  hears  God's  voice.  The  super- 
natural has  a  morbid  effect  on  the  imagination,  and  the 
voice-echoes  and  visions,  which  we  call  hallucinations,  are 
probably  due  to  mental  suggestion  in  not  a  few  cases.     One 

17 


258  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

girl  declared  that  at  night  in  bed  she  saw  a  vision  of  Christ, 
who  told  her  things  that  she  dared  not  reveal  to  anyone. 
Delusions  of  identity  are  not  infrequent,  and  they  may  be  of 
sexual  character. 

The  moral  sense,  especially  in  the  hysterical  form,  is  in 
abeyance.  There  is  no  regard  for  appearances.  The  patient 
kicks,  spits,  breaks  furniture  and  glass,  is  riotous  and  devil- 
may-care,  and  has  often  no  sense  of  decency,  being  wet  and 
dirty  in  habits,  and  given  to  masturbation.  Their  regard  for 
truth  is  none  of  the  best,  and  in  their  desire  to  appear  super- 
eminent  a  few  lies  are  but  a  trifle. 

The  melancholic  form  may  persist  as  a  type  by  itself,  but 
more  often  it  is  a  stage  in  the  cycle.  The  keynote  may  be 
religious  depression,  ideas  of  physical  degeneration,  a  nervous 
fear  of  something  about  to  happen,  or  ideas  of  suspicion  and 
persecution.  One  young  man — a  masturbator — said  that  he 
found  out  from  the  Bible  that  he  ought  not  to  work,  that 
'  the  wages  of  sin  is  death,'  and  that  he  was  suffering  from 
injuries  received  when  the  devil  was  chasing  him  over  the 
hills.  He  attempted  to  break  through  windows,  and  tried 
to  dash  his  head  into  the  fire.  He  refused  food,  and  had  to 
be  fed  for  a  long  time. 

Another  young  man  was  depressed  by  the  thought  that 
immoral  conduct  had  left  its  mark  on  his  visage,  his  teeth, 
etc.  A  young  girl's  delusion  was  that  bad  blood  had  been 
put  into  her,  that  her  tongue  went  by  machinery.  One 
girl's  fear  was  that  her  father  and  mother  were  going  to 
leave  her.  When  the  melancholic  state  disappears,  mania 
or  stupor  may  take  its  place.  Cataleptic  attitudes,  trances, 
automatic  movements,  rhythmic  monotonous  noises,  may 
also  characterize  the  insanity  of  adolescence. 

The  physical  condition  is  usually  one  of  anaemia,  especially 
so  in  cases  of  masturbation  and  amenorrhoea.  The  general 
bodily  condition  is  below  par,  with  pallor  of  skin,  flabbiness 
of  muscle,  and  a  general  deficit  of  secretions.  There  are 
exceptions  in  sthenic  cases,  with  the  mental  element  all-per- 
vading. One  such  was  a  young  farmer  of  robust  physique, 
whose  mental  furor  yielded  only  to  depressing  doses  of 
antimony,  and  there  are  cases  where  the  skin  secretions  are 


EVOLUTIONAL  AND  DISSOLUTIONAL  TYPES         259 

altered  or  in  excess.  The  pupils  are  usually  dilated,  the 
tongue  moist  and  flabby,  sometimes  furred.  Anorexia  is 
common,  and,  indeed,  it  may  be  said  that  want  of  tone  is 
usually  noticeable  in  the  performance  of  all  the  organic 
functions.  The  pulse  is  usually  soft  and  compressible, 
especially  in  the  states  of  melancholia  and  stupor,  and  at 
the  same  time  the  respiration  is  shallow.  Constipation  is 
not  infrequent,  but  there  is  no  characteristic  condition. 
The  urine,  so  far  as  I  have  been  able  to  learn  from  the 
researches  of  others,  and  especially  from  the  careful  estimates 
of  a  former  assistant  colleague.  Dr.  J.  T.  Maclachlan,  pre- 
sents no  special  features  unless  we  lay  stress  on  the  frequent 
presence  of  oxalates  in  the  depressed  and  stuporose  states 
associated  with  masturbation. 

Course  and  Prognosis. 

The  course  of  this  disease  is  a  devious  one,  as  will  be 
gathered  from  what  has  already  been  said.  The  ups  and 
downs,  the  corners  turned  without  the  daylight  of  sanity 
appearing,  are  perplexing  and  disappointing.  Nor  must  we 
regard  recovery  as  a  sure  prognosis  in  so  large  a  proportion 
as  you  might  suppose  from  the  fact  that  this  is  the  insanity 
of  youth.  The  favourable  estimate  given  by  Clouston  has 
not  been  reached  in  my  experience,  for  the  vice  of  masturba- 
tion has  debarred  recovery  in  many  cases.  The  recovery 
rate  of  my  cases  is,  males  30  per  cent.,  females  33  per  cent., 
and  a  few  of  the  males  were  masturbators.  Of  three  classes 
coming  under  the  category  of  insanity  of  adolescence,  I  find 
recovery  more  frequent  in  the  case  of  naturally  feeble-minded 
people  who  have  had  a  period  of  irritability  and  excitement, 
and  the  primary  idiopathic  type  not  associated  with  mastur- 
bation at  all.  The  fact  that  the  relapses  are  fewer  and 
shorter,  that  the  patient  is  gaining  in  weight  and  firmness, 
is  developing  in  masculine  or  feminine  figure  as  the  case 
may  be,  and  acquiring  a  more  solid,  stable  expression,  are  all 
good  signs.  But  you  will  be  surprised  in  many  cases  to  find 
that  the  amount  of  mind  restored  is  not  up  to  the  average 
of  the  time  of  life  of  the  patient.  You  cannot,  however, 
give  him  a  better  brain  than  he  had  before  the  attack. 

17 — 2 


26o  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

Treatment. 

This  is  a  question  of  general  hygiene,  personal  discipline, 
and  a  steady  building-up  of  physique.  The  patient  is  often 
in  a  state  of  reduced  bodily  condition.  This  may  be  due 
to  masturbation,  being  overworked  and  underfed,  or  living 
under  insanitary  conditions.  It  may  be  due  to  overstudy,  in 
a  high-strung,  nervous  subject  of  ambitious  temperament, 
with  neglect  of  meals.  The  history  in  every  case  will 
furnish  indications  for  treatment,  and  though  heredity  is  the 
essential  factor  of  all  these  cases,  incidental  influences  such 
as  have  been  indicated  may  have  a  telling  effect,  and  should 
receive  practical  consideration  in  the  treatment  of  the  case. 

The  patient  should  have  healthy  surroundings,  abundance 
of  pure  air  indoors  as  well  as  outdoors,  for  oxygenation  is 
below  par.  He  should  have  regular  outdoor  exercise  or 
employment,  and  live  in  the  open  air  as  much  as  possible. 
Thus  the  muscular  system  is  hardened,  the  bodily  functions 
are  stimulated,  and  sleep  is  promoted.  The  dietary  should 
be  chiefly  milk,  eggs,  and  farinaceous  food  ;  but  it  is  a  mis- 
take to  exclude  butcher's  meat  absolutely,  especially  if  manual 
labour  is  being  engaged  in,  for  the  physique  is  being  drawn 
upon,  and  it  has  not  yet  reached  its  maximum. 

The  use  of  sedatives  is  contra-indicated  except  in  emer- 
gencies, and  then  sulphonal  or  bromide  and  chloral  are  best. 
Attention  should  be  directed  to  hsemic  treatment,  for  the 
state  of  the  blood  is  very  unsatisfactory  in  most  of  the  cases, 
both  as  regards  the  percentage  of  haemoglobin  and  the  per- 
centage of  hsemacytes.  This  is  especially  noticeable  in  cases 
of  masturbation  and  disordered  menstruation.  It  is  a  well- 
known  fact  that  there  is  a  relation  between  gain  in  weight 
and  improvement  in  the  quality  of  the  blood,  and  everything 
possible  should  be  done  to  increase  the  weight  of  the  patient 
without  rendering  him  soft  and  flabby.  Liquid  extract  of; 
malt  is  most  useful,  cod-liver-oil  and  the  hypophosphites  are 
also  useful.  A  combination  of  quinine,  iron,  and  strychnine, 
as  pointed  out  by  Macphail  (Journal  of  Mental  Science, 
vol.  XXX.),  is  the  best  drug  combination.  This  experience  is 
confirmed  by  others. 


EVOLUTIONAL  AND  DISSOLUTIONAL  TYPES         261 

Many  indications  for  bodily  treatment  will  be  furnished 
by  different  cases,  and  if  the  treatment  be  successful,  a 
reflex  advantage  accrues  to  the  nervous  system  and  to  the 
mind.  Constipation  and  anaemia  may  be  treated  with  salts 
(Epsom)  and  iron,  or  pil.  Blaud,  and  Christison's  pill.  An 
irritable  stomach  often  yields  to  bismuth,  pepsin,  and  hydro- 
cyanic acid,  and  this  treatment  may  be  very  serviceable 
where  there  is  sickness  and  vomiting.  Most  difficulty  is 
experienced  with  hysterical  subjects,  who  are  sometimes  able 
to  eject  food  with  the  greatest  ease.  Blistering  over  the 
stomach  has  a  good  effect  in  many  of  these  cases,  relieving 
irritability,  and,  because  of  the  pain,  exercising  a  good  moral 
effect. 

Hysterical  Insanity. 

This  belongs  to  the  symptomatic  group ;  but  it  is  so  very 
frequently  associated  with  the  periods  of  puberty  and  adoles- 
cence that  I  introduce  the  subject  here.  It  has  intimate 
relations  with  masturbation  and  epilepsy  as  well,  because  of 
the  moral  perversion  which  characterizes  it.  Thus,  we  have 
hysteria  with  masturbation  as  a  leading  symptom,  and 
epilepsy  with  hysterical  symptoms  and  pseudo-seizures. 

The  gradations  of  hysterical  character,  till  it  reaches  the 
borderland  and  becomes  insane,  are  endless  in  number  and 
variety  as  the  differences  of  human  character ;  but  their 
fundamental  character  is  always  the  same  —  egotism  with 
moral  ablation,  great  or  small,  and  conscious,  though  irre- 
pressible, extravagance  of  emotion.  Hysteria  is  met  with  in 
a  simple  form  in  children — hysterical  laughter,  hysterical 
tears  ;  but  the  crisis  of  sexual  evolution  is  its  real  starting- 
point  as  we  are  accustomed  to  regard  it  from  a  medical 
point  of  view.  It  is  usually  confined  to  the  female  sex,  but 
the  male  sex  does  not  escape  altogether,  as  Charcot  has 
shown,  and  I  have  seen  a  few  cases  of  the  kind. 

The  nervous  organization  connecting  the  sexual  organs 
and  the  cerebro-spinal  centres  is  said  to  be  hyperassthetic  in 
many  such  cases,  if  not  in  all ;  and  there  is  now  no  question 
that  emotion  and  sexual  functions  are  intimately  correlated. 
In  many  cases  disease  of  the  uterus  and  ovaries,   and  dis- 


262  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

orders  of  menstruation,  are  exciting  causes,  and  when  to  this 
is  added  masturbation,  insanity  is  often  induced.  It  must 
be  borne  in  mind,  however,  that  hysterical  insanity  may  be 
quite  innocent  of  this  vice.  It  may  be  accepted  also  as  a 
fact  that,  beyond  a  nervous  hypersesthesia,  the  generative 
organs  ma}-  be  functional^  sound  and  structurally  intact. 

It  must  also  be  remembered  that  conditions  of  general 
ill  health,  anaemia,  chlorosis,  indigestion,  piles,  constipation, 
or  moral  causes  of  a  depressing  character,  ma}^  induce 
hysterical  symptoms  in  a  susceptible  patient.  Always 
remember  this,  that  a  careful,  methodical  examination  of  the 
physical  history  as  well  as  the  mental,  and  of  the  present 
phj'sical  condition,  are  of  the  highest  and  most  paramount 
importance.  This  rule  applies  ver}-  specially  to  hysteria, 
which  is  apt  to  be  the  subject  of  a  hasty  diagnosis,  and 
sometimes  a  rather  arbitrary  treatment. 

A  brief  summary  of  the  leading  features  of  hysteria  will 
appropriately  lead  up  to  the  consideration  of  insanity  of  this 
form.  (i)  There  is  self-consciousness  in  an  exaggerated 
degree,  to  the  occlusion  of  other  personal  considerations.  It 
is  none  the  less  noticeable  because  of  the  affectation  which 
tends  sometimes  to  disguise  it.  (2)  There  is  puerile  desire 
to  be  noticed  and  fussed  about,  and  made  much  of.  (3)  Fre- 
quently, for  the  reason  just  stated,  there  is  a  simulation  of 
disease  or  injury,  or  it  may  be  a  story  of  misfortune  more  or 
less  exaggerated,  or  perhaps  it  is  pure  fiction,  the  aim  being 
to  attract  notice.  (4)  The  following  symptoms  may  be 
noticed :  nervous — sensory  or  motor,  aneesthesise,  hyper- 
cesthesise,  paralyses,  convulsions  and  contortions,  globus 
h3'stericus,  polyuria ;  mental — emotional  outbreaks,  insane 
laughter  and  passion,  paroxysms  of  crying,  sexual  ex- 
travagances, moral  depravity.  All  these  latter  imph'  loss 
of  self-respect  and  self-control. 

It  is  impossible  to  sharply  define  hysteria  from  hysterical 
insanity.  The  case  of  ordinary  hysteria  is  no  more  insane 
than  the  febrile  patient  who  is  delirious.  We  must  have  the 
hysterical  state  deepened,  confirmed,  persistent,  a  distinct 
and  not  evanescent  degradation  of  moral  character,  overt 
acts  which  necessitate  restraint,  which  manifest  a  grave  loss 


EVOLUTIONAL  AND  DISSOLUTIONAL  TYPES         263 

of  self-control,  and  an  absence  of  all  sense  of  personal  re- 
sponsibility. For  example,  we  may  take  the  refusal  of  food 
for  days  by  hysterical  girls — the  fasting  girls  of  history  were 
hysterical  lunatics — or  we  may  take  actual  violence  to  self 
or  others,  destructiveness,  erotic  exhibitions  and  masturba- 
tion, as  diagnostic  signs.  Mere  threats,  though  sometimes 
they  lead  to  acts,  are  in  nine  cases  out  of  ten  pure  bravado, 
and  if  a  girl  threatens  suicide,  severe  moral  discipline  and 
unflinching  masterfulness  is  the  best  cure  for  her. 

The  intellect  may  be  wayward  and  disordered  in  its  action, 
but  impairment  is  not  usually  noticeable.  The  fault  lies 
more  in  the  emotional  and  moral  sphere.  As  has  been 
indicated,  passionate  outbursts  and  indecent  behaviour  are 
frequent,  and  masturbation  is  by  no  means  exceptional. 
You  will  be  surprised  to  find  this  in  the  most  unexpected 
quarters,  and  more  in  better-class  practice  than  among  the 
poor.  With  sexual  gratification  repressed  in  a  girl  with 
strong  sexual  cravings,  but  to  all  outward  appearance  at 
least  of  self-respecting  character,  the  passion  meets  with  a 
quasi  gratification  in  another  way,  and  after  long  pondering 
and  perplexity  regarding  the  significance  of  certain  symptoms 
in  a  difficult  case,  we  find  that  this  habit  has  been  secretly 
indulged  in  for  years. 

One  such  case  was  that  of  a  young  lady  of  exceptional 
talent  and  exquisite  musical  acquirements,  with  a  strong  ill- 
regulated  affection  for  the  opposite  sex.  She  had  been 
much  indulged,  was  self-willed,  and  did  very  much  what  she 
pleased.  She  had  a  disappointment,  became  insane,  and  was 
treated  at  home.  She  suffered  from  piles  ;  had  used  an  enema 
tube  for  years,  and  latterly  for  an  improper  purpose.  There 
was  an  absence  of  moral  rigour  in  the  nursing,  because 
she  had  not  been  removed  from  home.  The  nurses  soon 
discovered  her  masturbating  habits.  She  indulged  fiercely 
and  openly,  she  evinced  erotic  shyness  and  affectation, 
and  refused  food.  She  broke  out  into  attacks  of  noisy 
screaming  excitement,  would  jump  suddenly  out  of  bed  and 
commit  acts  of  violence.  All  the  time  there  could  be  no 
doubt  in  the  minds  of  those  who  saw  her  that  she  was 
consciously  thwarting  the  authority  and  well-meant  offices 


264  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

of  doctors  and  nurses,  and  straining  the  patience  and  in- 
dulgence of  her  parents  to  the  utmost.  She  ultimately 
recovered. 

In  this  form  of  insanity  impulses  of  sexual  character  are 
not  inhibited  to  any  extent,  but  suicidal  and  homicidal 
impulses,  though  always  possible,  are  more  rarely  given 
effect  to.  One  girl  escaped  from  the  asylum,  had  sexual 
intercourse  with  an  unknown  tramp,  and  when  brought  back, 
jumped  through  a  dormitory  window  and  broke  her  arm. 
Impulsive  attacks  are  more  frequent  at  or  near  the  menstrual 
periods.  They  frequently  have  sexual  delusions,  such  as 
that  they  are  enceinte;  that  they  have  given  birth  to  animals 
— rats,  mice,  etc. ;  that  women  are  men  and  men  women  ; 
and  many  of  their  ideas  and  suggestions  are  most  indecent 
and  erotic.  They  are  morally  degraded  for  the  time  being, 
and  are  capable  of  the  most  scandalous  accusations — figments 
of  the  insane  imagination. 

It  is  sometimes  difficult,  when  sensation  and  motion  are 
affected,  to  distinguish  between  true  hysteria  and  organic 
disease,  but  it  must  be  remembered  that  they  may  co-exist. 
For  illustration  of  this  fact  we  may  refer  to  the  case  quoted 
a  few  years  ago  in  Brain  by  Dr.  Hughes  Bennett,  the  case  of 
a  young  lady  of  exceptional  precocity  and  moral  depravity, 
who  indulged  her  sexual  passions  so  outrageously  that  she 
made  indecent  overtures  to  her  own  brother.  She  was 
examined  clinically  by  several  London  physicians,  neuro- 
logists of  eminent  reputation,  and  she  was  pronounced  a 
case  of  functional  hysterical  character,  despite  persistent 
blindness,  deafness  and  paraplegia.  She  died  some  months 
later,  and  post-mortem  examination  revealed  a  large  tumour 
in  the  medullary  substance  of  the  right  parietal  lobe  over 
the  lateral  ventricle. 

The  prognosis  is  usually  good  if  the  case  is  seen  and  put 
under  treatment  early,  but  I  have  found,  when  complicated 
with  influenza — the  hysterical  symptoms  being  consecutive — 
that  the  prognosis  is  not  so  good. 

The  treatment  must  be  much  on  the  lines  laid  down  for 
the  treatment  of  adolescent  insanity,  the  two  being  essen- 
tially of  the  same  natural  order  in  many  cases.     It  is  well 


EVOLUTIONAL  AND  DISSOLUTIONAL  TYPES         265 

always  to  look  for  bodily  symptoms,  to  pay  strict  attention 
to  physical  conditions,  to  have  the  patient  treated  under  a 
system  of  strict  moral  discipline,  and  away  from  home. 

Climacteric  Insanity. 

Is  there  such  a  period  as  the  climacteric,  and  when  ?  If 
so,  is  there  necessarily  a  form  of  insanity  that  can  truly  be 
called  climacteric  ?  Such  questions  have  been  put,  and 
doubts  have  been  raised  regarding  the  latter,  though  there 
can  be  little  question  as  to  the  fact  of  a  climacteric  epoch  in 
the  history  of  men  and  women  who  live  into  the  forties  or 
fifties,  or  it  may  be  the  sixties,  of  life's  milestones.  The  fact 
may  go  unchallenged,  albeit  the  epoch  may  appear  any  time 
during  these  twenty  years. 

Some  are  '  done'  men  early,  though,  wrinkled  and  withered, 
they  cling  on  to  life  for  years.  Others  abate  not  their  energy, 
their  wide  interests  and  their  usefulness,  and  retain  virility 
till  snow-capped  by  age.  Then  only  does  the  climacteric 
epoch  manifest  itself  in  a  disposition  to  relinquish  active 
pursuits,  a  lessening  interest  in  life's  affairs,  an  inability  to 
keep  pace  with  the  times,  and  a  disposition  to  narrow  the 
range  of  observation  to  home  and  personal  affairs.  The 
mental  dissolution  may  not  be  very  apparent,  or  at  all  rapid, 
but  it  has  begun.  This  period  begins  earlier  in  women,  and 
is  associated  with  cessation  of  menstrual  function.  In  men 
it  may  be  manifested  before  fifty,  but  usually  between  fifty 
and  sixty-five.  About  10  per  cent,  of  female  cases  admitted 
to  asylums  are  at  the  climacteric  period,  but  the  proportion 
of  males  is  much  less. 

The  rise  and  decline  of  the  sexual  function  mark  two 
epochs — puberty  and  the  climacteric ;  but  while  the  former 
is  identified  with  a  rise  of  self-consciousness,  and  a  distinct 
stride  in  mental  evolution,  the  latter  is  not  so  strikingly 
associated  with  diminished  self- consciousness  or  mental 
decline,  but  rather  with  a  slower  mental  pace  and  a  loss 
of  reactiveness,  mental  and  physical.  At  the  climacteric 
period  the  sensory  system  is  morbidly  affected,  the  opposite 
being  the  case  at  puberty,  where  the  motor  system  is  more 


•266  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

involved.  The  climacteric  is  subject  to  strange,  inexplicable 
sensations,  many  of  them  organic — to  neuralgia,  giddiness, 
headache,  aphonia,  and  other  affections.  The  drink-craving 
in  men  and  women  hitherto  temperate  may  now  show  itself. 
Undoubted!}'  there  is  a  failure  of  nervous  energy  and  a  jarring 
of  sensibilit}',  which  may  give  rise  to  great  pain  or  distress 
and  weariness  of  life.  The  keynote  of  the  altered  character 
now  met  with  may  thus  be  summed  up — fear,  anxiety,  sus- 
picion, loss  of  moral  courage.  To  this  may  be  added  for 
some  cases  sexual  aversion,  out  of  which  arise  delusions  of 
infidelity  on  the  part  of  wife  or  husband.  The  lack  of  moral 
courage  is  seen  in  the  man  whose  spirits  fall  to  zero,  who 
gets  depressed,  and  cannot  rally  from  the  shock  of  bad  news 
of  molehill  size  which  he  magnifies  into  a  mountain  of  mis- 
fortune. The  loss  of  a  few  pounds,  a  bad  debt  of  trifling 
amount,  a  mere  drop  in  the  ocean,  becomes  a  calamity  which 
he  believes  will  bring  his  affairs  to  a  state  of  bankruptcy. 
From  this  fear  emerges  the  further  suspicion  that  he  may 
be  regarded  as  fraudulent,  and  from  this  he  easily  entertains 
the  idea  that  he  will  be  cast  into  prison. 

In  another,  you  may  read  the  signs  and  watch  the  develop- 
ment of  the  attack  in  the  depressing  influences  of  anxiety 
and  domestic  trouble,  the  altered  marital  relations,  sexual 
aversion,  suspicion  of  husband's  fidelity,  hallucinations,  giving 
suggestions  of  persecution,  and  so  on  throughout  the  course 
of  chronic  progressive  delusional  insanity. 

The  maniacal  form  is  often  the  sequel  of  a  low  state 
of  physical  health,  whether  from  cardiac  or  other  organic 
disease,  malignant  disease,  nervous  inertia,  or  hepatico- 
intestinal  disorder.  Sometimes  it  is  religious  in  its  early 
manifestations,  or  the  excitement  may  be  passionate  and 
violent. 

The  most  prevalent  form  of  insanity  at  this  time,  as  might 
be  expected  where  sensation  is  so  frequently  involved,  is  the 
melancholic.  It  has  been  said  that  the  mental  depression, 
though  very  general  in  this  disease,  is  rarely  intense  ;  but 
the  intensity  and  the  suicidal  propensity  are  realty  more 
common  than  some  authorities  suppose.  This,  in  my  ex- 
perience, is  obvious  in  male  cases ;.  but  it  is  probable  that 


EVOLUTIONAL  AND  DISSOLUTIONAL  TYPES         267 

alcoholic  excess  has  something  to  do  with  it  in  a  few  of  the 
cases. 

The  forms  assumed  by  climacteric  insanity  in  male  and 
female  cases  are  different  in  their  relative  frequency.  Melan- 
cholia is  much  the  more  frequent  in  men,  and  the  hypo- 
chondriacal phase  is  frequent  and  characteristic  in  nearly 
half  of  the  melanchohc  cases.  Chronic  progressive  insanity 
and  mania  are  each  in  evidence  to  the  extent  of  about 
15  per  cent,  of  all  the  cases. 

In  the  female,  melanchoha,  mania,  and  chronic  progressive 
insanity  appear  in  about  equal  proportions.  Sometimes  is 
observed,  especially  in  females,  a  rebound  from  melancholia 
to  mania  with  exaltation.  A  few  cases  of  insanity  with 
delusions  of  persecution  by  unseen  agency,  or  ascribed  to 
overt  actions,  are  met  with  from  time  to  time ;  but  these 
may  be  fugitive,  intellectually  weak,  due  to  vague  fears,  and 
easily  recovered  from.  Several  clinical  illustrations  will 
follow,  and  so  unnecessary  repetition  is  here  avoided. 

It  is  rare  to  find  organic  brain  disease  associated  with 
climacteric  insanity  ;  but  cases  of  hemiplegia,  or  other  forms 
of  paralysis,  do  become  manifest  in  the  course  of  the 
disease. 

As  already  indicated,  the  bodily  health  is  impaired,  various 
nervous  phenomena  may  make  their  appearance,  and  there 
is  frequently  an  anaemic  condition,  which  may  be  very  per- 
sistent. Organic  sensations — uterine,  giving  rise  to  delusions 
of  pregnancy  or  otherwise  ;  gastro -intestinal,  giving  rise  to 
delusions  of  alimentary  occlusion  and  constipation,  are 
characteristic. 

Prognosis  is  fairly  good  if  in  the  male  the  form  is  melan- 
cholia, and  in  the  female  either  melancholia  or  mania.  The 
fact  that  chronic  progressive  insanity  is  so  frequent  a  form 
in  the  female  diminishes  pro  tanto  the  total  percentage  of 
curable  cases.  It  may  safely  be  estimated  that  40  per 
cent,  of  all  cases  recover,  and  in  my  experience  the  male 
rate  has  been  higher  than  the  female  rate.  If  there  be  grave 
impairment  of  memory,  or  signs,  however  slight,  of  organic 
brain  affection,  the  prognosis  is  not  so  good. 

Treatment  must  be  with  a  view  to  building  up  the  physical 


268  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

health,  increasing  weight,  improving  the  condition  of  the 
blood,  and  promoting  sleep.  Occupation,  especially  in 
melancholic  cases,  is  all-important.  Stimulants,  especially 
stout,  may  be  given  freely  if  there  is  no  craving.  As  far  as 
possible,  the  spent  force  must  be  restored,  and  a  liberal 
dietary,  including  the  nitrogenous  element,  must  be  pre- 
scribed in  a  manner  suitable  to  each  case.  As  a  blood  tonic 
arsenic  answers  well,  with  or  without  iron.  Syrup  of  hypo- 
phosphites  may  also  be  prescribed  with  advantage  in  many 
cases.  Attention  to  the  bowels,  which  are  frequent^  costive, 
to  the  state  of  digestion,  and  other  bodily  functions,  is  all- 
important,  and  must  not  be  overlooked. 

Senile  Insanity. 

The  preponderance  of  females  over  males  at  the  climacteric, 
becomes  reversed  in  old  age.  It  has  been  said  that  a  man's 
life  is  as  the  life  of  his  arteries,  and  the  most  significant  sign 
of  advancing  years  is  atheroma.  This  condition  may  exist 
however,  for  years  without  any  real  evidence  of  senility  ;  but 
when  you  have  also  to  notice  the  impaired  state  of  the  blood 
and  circulation,  to  the  evidences  of  somatic  failure  generally, 
the  shrinkage  of  tissues  and  organs,  and  the  slowing  of  the 
physiological  pace,  approaching  senilit}'  is  undoubted. 

As  regards  the  mental  question,  there  are  still  two  opinions. 
Many  regard  the  mental  shrinkage  or  involution  as  normal 
decay,  and  would  exclude  from  the  category  of  insanity  not 
a  few  cases  that  are  certified  insane,  while  others  regard 
such  cases  as  a  subgroup  under  the  name  of  senile  dementia. 
We  must  frankly  admit  that  many  old  men  are  no  more 
insane  than  we  are  ;  and  if  their  memories  have  failed,  and 
their  sympathies  have  dried  up  in  many  directions  where 
formerly  they  were  poured  out,  this  is  but  the  natural  out- 
come of  age,  and  does  not. portray  an  altered  and  insane 
personality. 

The  nomenclature  of  senile  insanity  is  not  uniform  through- 
out our  text-books.  Savage  treats  only  of  senile  melancholia  ; 
Spitzka  of  senile  dementia,  regarding  all  senile  forms  as  true 
cases  of  dementia  ;  and  Clouston  of  mania,  melancholia,  and 
dementia.     The  subdivision  of  Fiirstner  is  probably  nearest 


EVOLUTIONAL  AND  DISSOLUTIONAL  TYPES         269 

the  truth  :  (i)  functional  psychoses  ;  (2)  organic  psychoses 
(organic  dementia) ;  (3)  a  group  midway  between  the 
two. 

The  symptoms  may  be  maniacal  in  appearance  ;  but  when 
you  interpret  evidence  carefully,  it  will  often  be  found  that 
so-called  mania  is  the  delirium  of  a  demented  mind  and  an 
atrophied  brain.  In  like  manner,  many  cases  labelled  senile 
melancholia  are  mere  outward  symbols  without  correlative 
mental  pain,  whining  children  of  old  age  without  any  conscious 
sense  of  even  organic  discomfort. 

Following  the  arrangement  suggested  by  Fiirstner,  we 
reckon  up  senile  cases  as  follows  :  (i)  functional,  cases  of 
undoubted  mania  and  melancholia  without  evidence  of 
organic  disease ;  (2)  cases  which  may  be  functional,  but 
where  organic  disease  may  be  gravely  suspected — these  are 
usually  of  the  demented  class  ;  (3)  organic  dementia,  the 
result  of  haemorrhage,  thrombosis,  softening,  atrophy. 

The  mental  symptoms  are  of  two  kinds — those  which  are 
frequently  met  with,  and  those  which  are  not.  Of  the 
former,  nocturnal  disturbance,  roaming  about,  noisiness, 
excitement,  with  fits  of  somnolence  during  the  day,  loss  of 
memory  of  recent  events,  confusion,  absent  -  mindedness, 
affections  of  speech — amnesic  or  aphemic,  probably  both — 
emotional  weakness,  giving  rise  to  fits  of  crying  or  irritability. 
If  there  be  delirium,  it  is  the  delirium  of  old-world  experiences, 
the  phantasm  of  the  past,  the  old  b3^gone  days  lived  over 
again.  One  aged  creature  persists  in  the  idea  that  her 
husband,  who  died  twenty  years  ago,  is  still  alive  and  with 
her  ;  another  speaks  of  her  father  as  if  he  were  still  alive, 
and  she,  his  daughter,  had  just  come  home  from  school. 
The  earlier  the  reminiscence  redivivus,  the  deeper  the  ablation 
of  the  higher  centres. 

The  symptoms  not  so  general  are  those  of  the  functional 
form,  which  is  less  frequent  than  the  organic  or  incipient 
organic,  and  here  you  have  maniacal  or  melancholic  symptoms 
with  a  more  limited  range  of  morbid  intellection  than  in 
earlier  life.  In  the  maniacal  form  sexual  desire  may  be 
revived,  and  give  rise  to  atrocious  indecencies  which  mani- 
fest, not  only  weak  self-control,  but,  what  is  worse,  a  loss  of 


270  CLINICAL  MANUAL  OF  MENTAL  DISEASES - 

moral  sensibility.  Such  cases  may  have,  between  their  sexual 
delinquencies,  periods  of  apparent  sanity,  but  they  may  break 
out  again  at  any  time.  They  are  apt  to  contract  marriageSj 
December  with  June,  and  owing  to  their  mental  and  moral 
weakness  are  a  fit  prey  for  the  impecunious.  In  some  cases 
suspicion  and  delusions  manifest  a  different  type  from  the 
preceding,  vague  delusions  often  imperfectly  formed  and 
childishly  expressed — delusions  of  unseen  agency,  electric 
communications  fostered  by  hallucinations.  Sometimes 
kleptomania  is  a  symptom,  and  not  infrequently  the  senile 
maniac  may  be  ver}-  quarrelsome  and  violent. 

Senile  melancholia  is  more  frequent  than  mania.  It  is 
the  variety  of  insanity  in  old  age  best  known  and  most  fully 
described.  The  fundamental  condition  is  dread,  anxiety,  a 
vague  fear  of  something,  the  patient  knows  not  what.  It 
may  be  a  fear  that  her  money  will  be  stolen,  that  her  furniture 
will  be  taken  away  to  pay  the  rent,  that  the  house  will  be 
burned — but  why,  or  by  whom,  she  has  no  idea.  There  may 
be  suicidal  promptings,  but  they  are  feeble  in  initiative,  and 
if  they  lead  to  attempts  these  also  are  feeble.  While  this 
is  the  general  rule,  suicides  do  occur  in  old  age,  some- 
times because  of  mere  depression  of  bodily  stamina,  resulting 
in  a  weariness  of  life,  and  sometimes  from  other  causes,  such 
as  the  loss  of  wife  or  husband,  life  thereafter  becoming  in- 
supportable. In  senile  melancholia  the  patient  may  be  very 
restless  and  nois}',  especiall}'  at  night ;  the  lamentation  is 
often  very  loud,  and  there  is  a  childish  persistency  and 
craving  for  sympathy.  There  are  inconsistencies,  however, 
which  are  very  striking,  such  as  ceasing  at  meals  and  then 
crying  loudly  again  till  the  next  meal.  Here  the  melan- 
cholia is  less  real,  and  there  is  an  undoubted  element  of 
dementia  in  the  case. 

The  physical  condition  has  been  described,  but  in  some 
instances  there  are  in  addition  attacks,  in  the  course  of  the 
disease,  of  paralysis  in  a  variety  of  forms — apoplexy,  loss 
of  sight  and  hearing,  and  increasing  muscular  weakness. 
Diarrhoea  is  not  infrequent,  and  digestion  and  assimilation 
are  much  impaired.  The  prevalence  of  diarrhoea  again 
suggests   a   resemblance   to   childhood.     It    is    reflex   in    its 


EVOLUTIONAL  AND  DISSOLUTIONAL  TYPES         271 

origin,  post-mortem  examinations  rarely  giving  any  explana- 
tion of  it.     It  is  not  usual  in  normal  senility. 

The  etiology  of  the  disease  is  less  heredity  than  physical 
breakdown  and  mental  causes.  Ill-health  may  have  much 
to  do  with  it,  and  causes  which  age  a  man  prematurely. 

Prognosis. — Sometimes  recovery  occurs  in  the  maniacal 
formi,  and,  according  to  Clouston,  the  percentage  in  melan- 
cholic cases  is  30  per  cent.  This  is  a  higher  rate  than  one 
would  expect,  and  it  is  doubtful  whether  in  many  of  the 
cases  there  has  been  more  than  a  relief  of  the  acute  symptoms. 
That  genuine  recoveries  are  possible  where  there  is  no 
organic  degeneration  is,  of  course,  what  might  be  expected  in 
a  certain  moderate  percentage  of  the  cases. 

Treatment  is  summed  up  almost  in  one  word — good  care 
and  nursing.  The  enfeebled  powers  of  digestion  and  as- 
similation must  be  aided  by  what  is  digestible — the  plainest, 
simplest  diet,  warmth  and  stimulants.  These  old  men  and 
women,  by  reason  of  their  nocturnal  restlessness,  are  very 
trying,  and  need  to  be  guarded  like  children,  for  they  are 
liable  to  fall  and  sustain  injuries  that  may  hasten  their  end. 
Ecchymoses  are  very  easily  induced,  and  the  bones  are  easily 
broken. 

Clinical  Illustrations. 

Insanity  of  Puberty. 

I.  M.  C,  female,  at.  15,  is  very  illustrative  of  features 
rarely  combined,  but  all  characteristic  of  the  pathology 
of  puberty.  First  there  is  pronounced  heredity.  Father 
died  of  spinal  disease,  chorea  in  one  aunt  (paternal), 
and  insanity  in  two  maternal  relatives  (uncle  and  aunt). 
The  history  is  that  of  a  bright  child,  smart  at  school,  with 
no  adverse  circumstances  of  teething,  no  serious  ailments 
till  the  age  of  nine,  when  she  suffered  from  erysipelas 
of  the  face.  When  she  recovered  she  proved  a  backward 
child  at  school,  and  suffered  from  headaches.  A  year  ago 
(set.  14)  had  an  attack  of  rheumatic  fever.  Seven  weeks 
ago  had  a  second  attack,  not  so  acute,  but  as  symptoms 
were   subsiding   three   weeks    ago  chorea  supervened,   with 


272  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

mental  excitement  a  day  or  two  later.  Would  begin  to  cry, 
and  could  not  be  pacified  for  hours.  She  appeared  to  her 
friends  to  be  '  making  faces  in  the  looking-glass.'  She  had  no 
laughing  fits,  but  frequently  broke  out  into  singing  fits.  A  week 
later  hallucinations  of  sight  appeared.  She  imagined  she 
saw  a  dog  in  bed,  and  had  delusions,  such  as  that  her  father 
(dead  for  years)  was  at  the  door  and  could  not  gain  admit- 
tance, and  that  the  doctor  whom  she  had  known  for  years 
was  her  uncle.  Menstruation  was  established  eight  months 
before,  but  has  now  disappeared  for  at  least  four  months. 

On  admission  she  was  said  to  have  threatened  suicide,  a 
mere  impulsive  threat  on  hearing  that  she  was  to  be  sent  to 
the  asylum.  She  was  described  as  a  noisy,  frolicsome  tom- 
boy, and  her  mental  states  varied  between  exaltation  and 
depression  which  were  purely  emotional  and  fleeting.  The 
speech  was  slurred  and  interrupted.  She  would  begin  a 
sentence,  and  fail  to  finish  it ;  then  after  a  pause  the  words 
would  flow  freely.  She  was  still  choreic,  especially  in  left 
foot  and  hand.  The  breathing  was  more  diaphragmatic 
than  costal.  The  various  sensations  were  acute,  especially 
sensation  to  pain.  The  reflexes  were  well  marked,  especially 
the  abdominal  and  axillary. 

Her  expression  was  bright  and  animated,  she  was  on 
the  move  all  the  time,  and  did  not  sleep  night  nor  day  for 
some  days.  Her  temperature  was  subnormal,  but  on  the 
fifth  day  it  rose  with  rheumatic  symptoms,  and  the  mental 
and  choreic  symptoms  disappeared.  When  the  temperature 
receded,  mild  chorea  returned,  and  the  mental  symptoms  with 
it.  She  had  hallucinations  of  sight  and  hearing  ;  fancied  she 
heard  her  mother  speaking,  and  that  she  saw  two  women  in 
her  room. 

After  a  few  weeks  the  chorea  disappeared,  she  recovered 
her  former  health,  and  the  mind  was  restored. 

Insanity  of  Puberty — Summaries. 

n.  David  G.,  set.  14;  says  all  about  him  are  evil  spirits, 
but  he  is  '  the  just  God.'  Dancing  about  the  floor  all  night, 
would  not  keep  in  bed ;  mischievous,  and  biting  the  other 
patients.     He  has  a  skulking  expression  and  manner,  and  is 


Plate  VI.— EVOLUTIONAL  AND  DISSOLUTIONAL  TYPES. 


ADOLESCENCE    (MELANCHOLIA). 


ADOLESCENCE    (HVSTEKICAL    INSANITY). 


SENILE    DEMENTIA. 


SENILE    MANIA   WITH    GREAT    VAXITY 
AND   EXALTATION. 


To  face  p.  272. 


274  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

VII.  Richard  B.,  set.  22;  reduced  condition;  feeble 
musculation  ;  flabby,  pale,  and  cold  ;  circulation  very  feeble  ; 
tendency  to  chilblains  and  cyanosis ;  masturbator ;  quiet, 
curious  expression  ;  twirled  his  moustache  in  a  vain,  silly 
manner  ;  supercilious.  Refused  food ;  said  he  was  getting 
too  great  a  glutton  ;  pensive,  pathetic,  sorrowful  expression 
of  eyes.  Later  became  impulsive,  and  then  passed  into 
stupor  with  eyes  sunken  and  glazed,  showing  no  sign  of 
pupillary  reaction  nor  movement  of  the  eyeballs.  Was 
evidently  enthralled  by  delusions.  Out  of  this  state  he 
awoke,  sending  forth  a  piteous  wail,  and  next  moment  would 
strike  out.  Later  he  was  confined  to  bed,  with  flexion  of 
thighs  on  abdomen  and  legs  on  thighs ;  very  emaciated ; 
ulceration  of  skin  over  knees  with  black  slough.     Death. 

Vin.  Henry  A.,  set.  24,  is  a  more  exceptional  case,  but 
nevertheless  a  type  also.  He  lived  too  much  a  woman's  life 
at  home  with  his  mother ;  could  cook  or  do  housework  like 
herself.  On  admission  his  condition  was  one  of  exaltation, 
with  an  appearance  of  reason  and  shrewdness  not  usual  in 
the  adolescent.  He  said  he  was  inspired  by  God  to  make 
statements  that  God  shall  arise  and  terribly  shake  the  earth. 
Exalted  ideas  of  his  intellectual  powers.  Exalted  religious 
emotions ;  described  himself  as  '  a  man  of  sorrows  and  ac- 
quainted with  grief.'  Childish,  petulant,  suspicious.  Some- 
times thought  he  was  next  to  Christ,  but  when  brought  to 
book  for  this  statement  he  extricated  himself  by  saying  it 
was  a  mere  exaggeration.  Most  useful  in  the  hospital ;  just 
like  a  woman.  Good  face,  refined,  intellectual,  but  nervous 
instability  of  expression,  especially  convulsive  twitchings 
round  the  eyes.  Facile  sometimes,  and  easily  managed  ;  but 
he  was  also  a  strange  compound  of  reason  and  suspicion. 
Refused  to  answer  certain  questions,  for  he  was  sure  that  by 
some  quibble  I  wanted  to  put  him  in  a  corner.  Thought 
that  shaving  his  head  for  alopecia  was  submitting  him  to 
an  indignity.  Hereditary  insanity  strongly  marked.  Got 
strong  and  robust  and  recovered. 

IX.  Isabella  R.,  set.  24 — marked  hereditary  history. 
Imagined  herself  the  mother  of  her  sister's  child,  and 
threatened    her   sister's    life ;    memory    weak ;    abstraction. 


EVOLUTIONAL  AND  DISSOLUTIONAL  TYPES         275 

Actions  sudden  when  doing  anything ;  no  self-control. 
Attacked  another  patient  under  the  delusion  that  she  was 
her  sister.  Dysmenorrhoea  with  deficient  flow  ;  headache 
before  menstruation,  very  irritable  and  impulsive  then  and 
during  the  flow.  Giddiness  and  vertical  headache  after- 
wards ;  anaemia.  This  patient  recovered  partially  and  then 
relapsed. 

X.  Annie  M.,  set.  20.  Threatened  to  drown  and  poison 
herself;  admitted  it;  stupid  and  dull;  amenorrhoea ; 
brightened  up  ;  recovered. 

XI.  Nellie  B.,  set.  18.  Been  insane  at  puberty  and  re- 
covered. Stubborn  ;  melancholic  ;  fought  obstinately  when 
attempts  were  made  to  rouse  her  ;  cataleptic  ;  gleams  of 
brightness  and  energy  for  two  days,  then  would  relapse  ; 
gleams  of  longer  duration  ;  sews.  Very  silly ;  laughs 
foolishly ;  wrote  irrelevant  amorous  letter ;  hallucinations 
of  sight ;  saw  her  brother  in  mid-air.  Later  excited,  im- 
pulsive, vain;  liked  to  be  taken  notice  of;  erotic  in 
behaviour.  Mental  see-saw ;  ebb  and  flow ;  affected  by 
menstrual  periods.     Recovery. 

XII.  Mary  L.,  set.  24.  This  case  was  for  a  long  time 
seemingly  hopeless.  The  recovery  has  been  most  satis- 
factory, and  she  has  been  well  for  twelve  years.  Extracts 
from  case-book  :  '  Hilarious  ;  dances  and  sings.  Excitement 
comes  in  gusts.  The  ward  is  '  the  King's  room  '  ;  throws 
her  clothes  about  ;  refuses  food ;  amenorrhoea  for  several 
months  ;  then  menstruation  irregular ;  later,  regular.  Gets 
into  stupid  moods,  with  lowered  eyebrows  and  fixed  stare ; 
expression  vacant ;  costive.  Is  passing  into  stupor  after  a 
full  month's  lucidity.  Inflammation  of  knee  and  leg  ;  sup- 
puration ;  health  afterwards  much  improved.  Treated  with 
defibrinated  blood.     Recovery. 

XIII.  Jeannie  Y.,  set.  20.  Saw  a  vision  of  angels,  and  a 
voice  said,  '  Trust  in  Nellie.'  Says  the  room  is  a  steamboat, 
and  that  she  is  on  her  way  abroad.  Later  thinks  she  is  in 
the  convalescent  home,  which  is  nearer  the  mark,  for  she  is 
now  convalescent.  Had  delusions  of  identity.  Suffered 
from  amenorrhoea.     Ferruginous  treatment.     Recovery. 

18—2 


276  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

Climacteric  Insanity — Summaries. 

XIV,  Mrs.  A.  B.,  ast.  44 — melancholia.  This  patient's 
attack  was  said  to  be  due  to  persistent  dyspepsia,  constipa- 
tion and  haemorrhoids,  but  these  were  aggravated  by  the 
'  time  of  hfe.'  She  attempted  suicide  by  cutting  her  throat 
with  a  razor.  She  was  in  a  state  of  melanchoha  which  she 
could  not  explain.  Her  physical  condition  on  admission 
was  that  of  exhaustion  ;  the  suicidal  wound  was  not  deep, 
but  the  digestive  tract  was  in  a  very  unsatisfactory  state. 
The  nostrils,  lips,  mouth,  and  fauces  were  raw  and  tender, 
and  the  gastric  irritation  so  great  that  rectal  injections  of 
partly-digested  food,  peptones  in  milk,  and  stimulants,  had  to 
be  freely  given.  The  throat  was  swabbed  with  glycerine  of 
borax.  She  slept  very  little,  but  her  distressing  wakefulness 
was  relieved  by  warm  baths.  Her  weight  on  admission  was 
92  pounds.  At  the  end  of  a  year  she  had  gained  30  pounds 
in  weight,  and  her  mental  recovery  was  complete, 

XV,  Mrs,  C,  B.,  get.  47 — melancholia.  Taciturn,  slow  to 
converse ;  said  that  God  had  forsaken  her,  that  she  was 
quite  miserable,  and  wanted  to  die.  She  bemoaned  the 
paralysis  of  her  will,  and  her  inability  to  work,  although  there 
was  so  much  need  for  her  to  do  so.  She  declared  that  she 
was  so  filthy  that  the  water  got  thick  with  dirt  when  she 
put  her  hands  in  it ;  that  everything  in  the  house — clothing, 
napery,  furniture,  etc. — was  filthy..  After  a  time  she  engaged 
in  active  employment  and  recovered. 

XVI.  Mrs.  C.  S.,  set.  53 — melancholia.  This  patient  was 
much  depressed,  and  broke  out  from  time  to  time  in  frenzies 
of  melancholic  excitement ;  declared  that  her  children  were 
taken  from  her,  that  she  was  lost,  and  her  relatives  were 
conspiring  against  her.  She  was  more  depressed  in  the 
afternoon  and  evening.  Health  below  par  ;  constipation  ; 
appetite  poor.  She  believed  women  were  men,  and  she 
suffered  from  hallucinations.  Treatment  by  bromide  of 
potassium  and  tr.  cannabis  indica  was  very  successful. 
Recovery. 

XVII.  Mrs,  M.  G.,  aet.  46 — melancholia.  Noises  in  the 
head,    very    excited    and    violent,    and  quite   beside   herself. 


EVOLUTIONAL  AND  DISSOLUTION AL  TYPES  277 

Declares  she  is  lost,  and  that  she  has  killed  her  father  and 
mother,  and  also  her  own  boy.     Recovered. 

XVIII.  John  M.,  get.  57 — melancholia.  Nervous,  anxious, 
troubled  expression  ;  atheroma,  emphysema ;  abdomen  ex- 
tremely retracted ;  a  case  of  melancholia  which  began  with 
mild  climacteric  depression  intensified  by  neglect  and  starva- 
tion. Bromide  and  cannabis,  stimulants,  and  liberal  dietary. 
Recovery. 

XIX.  Mrs.  M.  C,  set,  55 — mania.  Violent  ;  raves  in- 
cessantly and  incoherently.  Says  she  sees  the  Virgin  Mary 
and  hopes  the  devil  will  take  her  husband  ;  that  the  marrow 
is  coming  out  of  her  bones  with  the  cold ;  hyper-pyrexia  and 
flying  pains  through  the  body;  looks  weak;  lips  dry,  tongue 
foul,  stools  offensive,  complexion  sallow;  stimulants,  salicylate 
of  soda.     Recovery. 

XX.  Mrs.  R.  A.,  aet.  47 — mania.  Greatly  excited ;  said 
she  was  a  general,  and  gained  Lord  Raglan's  victories. 
Pulse  108  ;  no  rise  of  temperature,  but  gastro-hepatic  dis- 
order ;  tongue  foul,  costive,  stools  greenish-brown ;  refuses 
food  ;  homicidal  (got  nurse  down  on  the  floor),  destructive  ; 
says  she  is  the  Queen ;  sleepless ;  pin-head  pupils.  Slept 
after  vin.  antimonialis.  Bromide  and  cannabis  did  good  ; 
lost  weight,  but  recovered. 

XXI.  Mrs.  K.,  set.  47 — alternating  insanity,  melancholia 
followed  by  mania.  First  attack :  Threatened  to  commit 
suicide  ;  refused  to  speak ;  sleepless ;  walked  the  floor 
during  the  night.  Reflected  morbidly  on  her  conduct  to- 
wards her  family ;  very  thin ;  exophthalmic  goitre.  Had 
religious  scruples  and  misgivings,  and  allowed  herself  to  get 
into  a  weak  and  wretched  state  of  health.  Under  tonic 
treatment  with  extra  diet  she  put  on  flesh  and  regained  her 
former  cheerfulness.  Discharged  recovered.  Second  attack  : 
Six  months  later  became  maniacal ;  could  not  rest  night  nor 
day  ;  talked  of  getting  married  to  a  millionaire  ;  threatened  to 
cut  her  son's  head  off  with  a  large  knife  ;  broke  the  windows 
of  the  house  ;  threw  out  the  furniture  ;  bought  unnecessary 
articles  and  got  deeply  into  debt.  She  was  quarrelsome  and 
officious,  and  had  grandiose  delusions  of  position,  wealth,  and 
possessions.     Bodily  condition  much  reduced.     She  is  now 


278  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

quiet  and  rather  depressed,  and  will  probably  become  melan- 
cholic again. 

XXII.  Mrs.  H.  C,  set.  42 — chronic  progressive  delusional 
insanity.  Has  the  delusion  that  darts  are  thrown  at  her,  which 
enter  her  brain  and  carry  the  mind  of  the  person  who  throws 
them  into  her  mind.  Expression  curious  and  careworn  ; 
aortic  disease.  Later  she  thinks  she  is  a  person  of  great 
importance,  and  can  command  legions  of  soldiers.  Hallu- 
cinations of  hearing  for  a  long  time. 

XXIII.  ]\Irs.  N.  H.,  set.  55 — chronic  progressive  delusional 
insanity.  Insane  five  years  ;  says  her  husband  and  friends 
wish  to  poison  her,  and  imagines  he  (her  husband)  chloro- 
formed her  while  others  ravished  her  (has  uterine  disease). 
Filled  all  the  crevices  in  the  house  to  prevent  the  neighbours 
suffocating  her  with  sulphur.  Hears  her  husband  con- 
versing with  strange  women  at  night  (hallucination) ;  h5'po- 
chondriacal.     Transferred  to  another  asylum. 

XXIV.  John  H.,  set.  60 — hypochondriacal  melancholia.  De- 
pressed and  suicidal.  Has  for  a  long  time  complained  of 
pain  over  vertex,  and  sleeplessness.  Is  very  self-centred  and 
hypochondriacal.  Is  continually  thinking  about  his  health. 
Thinks  he  has  no  stomach,  that  his  bowels  are  blocked  up, 
and  refuses  food.  Constipated.  Tonic  and  laxative  treat- 
ment.    Recovered. 

XXV.  Mrs.  M.  C.  R.,  set.  65 — senile  melancholia.  Was  of 
anxious,  sensitive  character  ;  would  brood  over  matters  and 
keep  thoughts  to  herself.  Got  the  idea  that  her  throat  was 
choked  up  and  she  could  not  swallow,  but  this  idea  dis- 
appeared as  soon  as  she  became  excited.  Was  in  a  state  of 
insane  terror  on  admission,  under  the  idea  that  the  house 
was  on  fire.  She  had  delusions  that  (i)  her  head  was 
diminished  in  size  by  fumes  of  sulphur,  and  (2)  the  old 
delusion  that  her  throat  was  closed  returned.  The  melan- 
cholia degenerated  into  a  childish  wail  that  went  on  da}^  and 
night,  except  at  meals,  which  she  devoured  ravenously,  till 
she  suffered  from  lung  disease,  of  which  she  died. 

XXVI.  Mrs.  B.  H.,  set.  67 — senile  melancholia.  Says  that 
the  devil  has  got  possession  of  her,  and  is  urging  her  to 
drown  herself.     Talks  in  a  very  depressed  tone  to  the  effect 


EVOLUTIONAL  AND  DISSOLUTIONAL  TYPES         279 

that  there  is  no  escape  for  her,  and  that  she  will  drown 
herself.  Can't  sit  quiet  for  more  than  a  few  minutes  at  a 
time  ;  is  restless  night  and  day.  Memory  good  for  her  age  ; 
fairly  coherent.  Says  God  has  forgotten  her.  She  is  self- 
reproachful.     Health  improved.     Recovered. 

Senile  Insanity — Swninaries. 

XXVII.  W.  B.,  aet.  74 — senile  mania.  Alcohol  the 
exciting  cause ;  tall,  well-built  old  man  ;  very  sleepless, 
excited,  oblivious,  delirious ;  does  not  know  where  he  is,  but 
talks  incoherently  of  the  past.  Very  stupid  and  confused. 
Delirium  passed  off.     Recovered. 

XXVIII.  Mrs.  M.,  set.  79 — senile  mania.  Was  in  a 
transient  state  of  excitement,  and  could  not  be  brought  to 
reason.  Said  her  sons  were  burned,  and  next  moment  that 
parts  of  their  bodies  were  blown  away.  Was  very  excited 
and  could  not  rest,  but  recovered  as  from  a  dream. 

XXIX.  Mrs.  McG.,  set.  64 — senile  dementia.  Has  no  idea 
where  she  is  ;  says  her  son-in-law  will  burn  her ;  gives  her 
age  as  eighty,  then  says  she  is  seventy;  aortic  disease; 
bowels  opened — 20  ounces  hard,  dark,  stony  faeces ;  very 
bent,  but  straighter  after  bowels  relieved ;  several  mild 
shocks  and  convulsive  seizures  ;  retention  of  urine.     Death. 


CHAPTER  XIV. 

INEBRIETY—ALCOHOLIC  INSANITY— OTHER  FORMS  OF 
INEBRIETY— SYPHILITIC  INSANITY. 

Definition  of  inebriety  —  The  agent  may  be  alcohol,  opium,  or  other 
narcotic — Alcohol  as  a  cause  of  insanity — The  plea  of  intoxication 
in  exculpation  of  crime — The  action  of  alcohol  in  respect  to  nervous 
and  mental  symptoms  widely  differentiated  —  Transitory  alcoholic 
mania — Delirium  tremens — Acute  alcoholic  mania — Dipsomania — 
Chronic  mania — Alcoholic  dementia  —  Opium  and  other  medicinal 
stimulants — Their  nervous  and  mental  effects — Syphilitic  insanity  a 
conventional  rather  than  a  scientific  term  —  Varieties:  primary; 
secondary  ;  delusional,  with  or  without  brain  lesion  ;  organic  — 
Clinical  illustrations. 

^  Is  the  inebriate  but  a  fool  ?  Is  he  but  a  wanton  and  wicked 
sinner  ?  .  .  .  Emphatically  does  science  answer  No.  Men 
and  women  of  the  highest  culture,  the  purest  life,  the  most 
exalted  aims,  have  become  reckless  drunkards.  .  .  .  The 
warmest  hearts,  the  kindest  souls,  the  most  unselfish  spirits, 
have  been  transformed  under  the  siren  influence  of  "the 
tricksy  spirit "  into  the  coldest,  most  unkind,  and  most 
selfish  votaries  at  the  shrine  of  Bacchus.' — Dr.  Norman 
Kerr. 

The  popular  meaning  of  '  inebriety  '  is  drunkenness  from 
alcoholic  excess,  and  there  is  ancient  warrant  for  this  con- 
ception of  the  term,  albeit  its  derivation  from  inebrio,  is 
drunkenness,  without  any  qualification.  The  agent  may  be 
alcohol,  opium,  ether,  chloral,  chloroform,  cocaine,  or  any 
other  intoxicant  having  a  delirious  or  narcotic  effect  on  the 
nervous  system. 

The  principal  and  most  common  agent  is  alcohol,  and  the 
study  of  its  effects  has  given  rise  to  diverse  opinions  as  to 
which  are  products  of  disease,  and  which  products  of  physio- 


ALCOHOLIC  INSANITY 


logical  exaltation  and  its  reactions.  With  the  physiology  of 
ordinary  alcoholic  drunkenness  this  chapter  has  no  concern  ; 
but  it  is  important  to  observe  that  the  amount  of  alcohol  does 
not  necessarily  determine  the  mental  result,  but  the  individual 
himself,  his  nervous  organisation  and  attendant  circum- 
stances must  be  taken  into  account. 

Alcohol  as  a  cause  of  insanity  has  been  variously  estimated, 
and  immoderate  statements  have  frequently  been  indulged 
in,  so  that  a  clear  perception  of  the  actual  facts  of  the  case 
has  been  obscured.  According  to  Clouston,  15  to  20  per 
cent,  of  all  cases  of  insanity  are  more  or  less  due  to  alcoholic 
excess.  This  reservation  more  or  less,  or,  to  use  Clouston's 
phrase,  in  whole  or  part,  does  not  give  data  of  accurate  scientific 
value,  and  read  in  conjunction  with  the  following  remark 
from.  Savage,  the  uncertainty  about  the  matter  is  still  more 
evident.  The  latter  observes  :  '  In  my  experience  one  of  the 
most  common  tendencies  of  early  lunacy  is  to  seek  for  sleep, 
relief  from  pain,  excitement,  or  alleviation  of  trouble,  in 
drink.  In  such  cases  the  nervous  disturbance  was  already 
fairly  started  before  the  drink  was  taken  to  excess.'  It 
may  be  added  that  if  the  drink  had  been  taken  as  a  narcotic 
medicine  early,  in  order  to  procure  sleep,  the  attack  of  insanity 
might  have  been  averted. 

That  drink,  and  especially  bad  drink,  is  a  potent  influ- 
ence, and  a  cause  of  insanity,  cannot  be  denied  ;  but  a  weak, 
nervous,  susceptible  constitution  is  often  the  medium  of  its 
malign  operations,  and  the  individual  as  well  as  the  agent 
must  be  closely  examined.  It  is  sometimes  difficult  to  dis- 
tinguish between  the  physiological  and  pathological  inebriate, 
and  such  distinction  is  urgently  required  in  not  a  few 
of  the  cases  committed  for  trial  for  civil  and  criminal 
offences  when  under  the  influence  of  alcohol.  Notwith- 
standing that  judicial  decisions  are  often  more  lenient  now 
than  formerly,  it  is  doubtful  if  Dr.  Kerr's  argument  would 
be  sustained,  viz.,  '  that  a  plea  of  intoxication,  unless  the 
drinking  has  been  purposely  indulged  in  to  steady  the  nerves 
for  the  commission  of  a  crime,  should  be  admissible  in 
defence.' 

The  drink  craving  is  a  result  of  disease   in   many  cases. 


282  CLIXICAL  MANUAL  OF  MENTAL  DISEASES 

There  can  be  no  question  of  that.  The  disease  may  originall)^ 
be  somatic  disease  acting  secondarily  on  and  depressing  the 
nervous  system.  It  may  instead  be  due  to  nervous  depression,, 
the  result  of  exhausting  demands  on  the  bodily  and  nervous 
energies,  to  neuralgia,  injuries,  domestic  and  other  worries 
and  anxieties,  business  failure,  etc.  As  a  convivial  habit  it 
is  less  excusable ;  and  here  is  the  fans  ct  origo  of  many  cases 
of  alcoholic  degeneration,  especially  when  the  indulgence  is 
attended  with  great  mental  excitement,  which  is  frequent!}^ 
the  case  in  the  tap-room,  and  in  company  elsewhere. 

Alcohol  during  business  hours,  if  work  is  to  be  done,  is 
bad.  Mental  confusion  is  the  result ;  irritation,  because  of 
mental  failure  to  accomplish  what  can  only  be  done  by  a. 
clear  head,  aggravates  the  sense  of  brain  discomfort,  and 
often  causes  flushing  of  the  face  and  headache.  If  alcohol 
must  be  indulged  in,  whether  for  sleep,  organic  comfort,. 
or  the  sense  of  mental  well-being,  it  is  best  left  alone  till 
the  evening,  when  work  is  done,  the  day's  excitement  over,, 
and  mental  exercise  is  no  longer  necessary  or  desirable. 

The  action  of  alcohol,  and  its  effects  in  respect  to  nervous 
and  mental  s3'mptoms,  are  so  differentiated,  and  so  apparently 
quixotic,  that  we  must  take  a  general  view  and  widen  the 
classification  of  this  form  of  insanity  without  being  arbitrary.. 
As  already  indicated,  the  individual  himself  is  the  determin- 
ing factor  as  to  the  mental  and  nervous  result  of  his  libations, 
and  the  latter  operate  pathologically  when  nerve  resistance  is 
vanquished. 

The  implication  of  the  nervous  system  may  be  the  only- 
symptom,  or  mental  S3'mptoms  may  predominate  to  the- 
almost  entire  exclusion  of  nervous  symptoms.  The  motor 
system  ma}'  alone  be  affected,  general  tremor  being  visible- 
throughout.  There  may  be  instead  of  this  involuntary 
startings,  with  or  without  hallucinations.  Epileptic  con- 
vulsions may  occur  after  prolonged  potations.  Dagonet  and 
others  consider  these  convulsions  to  have  a  more  deteriorating- 
effect  on  the  mental  condition  than  the  seizures  of  ordinary 
epilepsy,  Alexander  Robertson  disputes  the  accuracy  of  this 
statement,  at  least  in  our  country,  where  the  alcohol  imbibed 
is  regarded  as  less  poisonous  than  absinthe  (vide  International 


ALCOHOLIC  INSANITY  283 


Journal  of  Medical  Science,  December,  1892).  Peripheral 
neuritis,  motor  as  well  as  sensory,  may  be  in  evidence. 
Pupil  symptoms,  especially  inequalities,  may  occur,  and 
often  persist  after  recovery.  In  one  case  of  acute  insanity 
under  my  care,  with  lucid  intervals,  there  is  permanent 
inequality  of  the  pupils.  The  onset  was  due  to  the  first  and 
last  bout  of  alcohohc  excess — a  very  trifling  one  as  hardened 
sinners  in  this  respect  would  judge  it  ;  but  the  patient's 
father  has  been  a  chronic  soaker  for  years,  a  man  of  great 
natural  ability,  and  a  man  who  has  never  yet  been  insane. 

The  sensory  symptoms  are  more  limited.  It  is  true  that 
multiple  neuritis  may  affect  such  patients,  but  the  special 
senses,  sight  and  hearing,  are  most  liable  to  be  affected. 
As  showing  that  here  the  hallucination  or  illusion  is  often 
sensory  rather  than  of  mental  origin,  it  is  interesting  to 
observe — and  this  is  clearly  brought  out  by  Robertson — that 
in  many  cases  the  hallucination  is  not  full-blown  at  once. 
At  first  shadowy  and  vague — a  cloud,  coloured  stars,  etc. — it 
soon  takes  on  a  more  definite  and  complex  form.  In  acute 
alcoholic  insanity  hallucinations  of  sight  usually  precede 
those  of  hearing,  but  in  more  chronic  states  the  latter  holds 
the  field  usually  alone,  and  the  hallucinations  may  be  one- 
sided. 

The  condition  of  the  skin  glands,  sudoriferous  and 
sebaceous,  is  also  interesting.  Except  in  highly-fevered 
states  there  is  more  or  less  perspiration,  but  it  is  not 
necessarily  continuous.  The  oleaginous  skin  of  alcoholism 
has  frequently  been  noticed,  but  it  is  rather  a  symptom  of 
the  chronic  form. 

The  mental  response  to  alcoholic  libations,  whether  positive 
or  negative,  is  as  varied  as  the  individual  himself,  and  merely 
by  way  of  landmarks  the  following  distinctions  are  drawn  r 
(i)  Transitory  alcoholic  mania,  (2)  delirium  tremens, 
(3)  acute  alcoholic  mania,  (4)  chronic  mania,  (5)  alcoholic 
dementia. 

Transitory  alcoholic  mania,  sometimes  called  mania  a  potic 
(mania  from  drink),  or,  better  still,  delirium  ebriosum,  is  in 
popular  language  the  state  described  as  '  mad  drunk.'  It 
may  only  last  a  couple  of  hours,  or  a  day  at  most,  and  is 


284  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

most  sudden  in  its  onset.  The  drink,  to  quote  another 
popular  phrase  also  quoted  by  Savage,  '  flies  to  the  head  '  ; 
the  subject  is  very  susceptible  ;  very  little  alcohol  will  do, 
and  what  little  there  is  imbibed  has  a  selective  affinity  for 
brain  tissue,  producing,  as  a  rule,  sudden  mental  irritation, 
for  such  persons  are  often  exceedingl}.'  violent.  I  have  known 
a  young  fellow  of  very  excitable  disposition  appear  at  a  social 
function  at  8  p.m.,  drink  two  glasses  of  whisky,  and  be 
in  a  police  cell  at  lo  p.m.  Next  morning  he  wakened  up 
from  a  sound  sleep,  and  had  no  recollection  of  the  row  of  the 
preceding  night,  but  was  perfectly  sane.  There  is  something 
suggestive  of  post-epileptic  furor  in  transitor}-  alcoholic 
mania.  The  oblivious  condition,  the  riotous,  aggressive 
violence,  the  delirious  abandon,  give  an  ensemhle  very 
suggestive  of  epilepsy. 

Delirium  tremens  has  four  cardinal  symptoms  :  (i)  motor 
disorder ;  (2)  hallucinations,  especially  of  sight ;  (3)  insane 
fear  and  terror  ;  (4)  acute  delirium.  Certain  men  are  always 
affected  in  this  way  when  they  take  drink  to  excess,  and 
Robertson  has  had  experience  of  cases  with  as  many  as 
twelve  to  twenty  attacks,  all  of  this  form.  In  many  cases 
the  drink  habit  is  suspended  for  several  days  before  the 
onset  of  an  attack  ;  in  some  there  seems  to  be  an  aversion 
to  it  at  the  very  last  moment.  The  state  of  the  bodily 
health  has  much  to  do  with  it  also,  for  such  men  are  often 
in  a  reduced  physical  condition  and  empty  of  food  for  days. 
This,  along  with  want  of  sleep,  makes  them  a  more  easy 
prey  to  the  poisoning  which  necessarily  results,  especially  if 
the  kidnej'S  and  bowels  are  inactive. 

The  patient  is  often  in  a  crouching  attitude,  .  his  eyes 
staring,  his  expression  one  of  fear  or  terror.  He  evidently 
sees  things  invisible  to  others.  Ask  him  what  he  sees  and  he 
will  tell  you,  pointing  to  them  :  ferrets,  rats,  serpents,  dogs, 
cats,  or  any  other  animals ;  it  may  be  that  he  is  fleeing  from 
devils  or  ghosts,  or  the  hallucinations  may  be  of  a  less 
terrifying  character.  The  state  of  terror  is  often  aggravated, 
and  the  hallucinations  more  vivid  when  the  patient  is  put  in 
a  dark  room  alone,  especially  at  night. 

It  will  be  noticed  there  is  more  or  less  tremor;    it  may 


ALCOHOLIC  LNSANITY  285 

be  merely  facial  or  lingual,  but  more  frequently  the  general 
motor  system,  especially  the  hands  and  feet,  show  the 
trembling  movements  which  are  so  characteristic  in  many 
cases.  Some  exhibit  tremor  after  all  other  symptoms  have 
disappeared. 

The  patient  is  more  or  less  oblivious  of  his  position.  I 
have  known  a  man  develop  an  attack  of  delirium  tremens  on 
board  ship,  and  in  the  height  of  it  lift  a  portmanteau  from 
his  cabin  (on  deck)  and  try  to  get  overboard,  not  realizing 
the  treacherous  footing  to  which  he  would  consign  himself, 
or  the  fact  that  we  were  at  sea,  not  on  land.  He  had  got 
the  idea  of  a  train  and  a  railway  station  into  his  head. 

The  excitement,  marked  diminution  of  consciousness, 
hallucinations  of  vision,  with  fear  and  terror,  rend  the  man 
asunder  as  it  were,  resulting  in  a  state  of  frenzy  in  some 
cases,  but  in  all,  what  we  call  delirium,  a  man  beside  himself, 
without  power  to  reason  or  reflect,  the  sport  of  his  insane 
hallucinations. 

The  crouching  attitude  may  change  to  a  movement  of 
flight,  a  struggle  to  be  free  and  escape,  and  a  fatal  issue  may 
be  the  result.  Delusions  of  identity  are  not  uncommon, 
both  of  time  and  place.  One  poor  fellow  travelled  from  the 
North  of  Scotland,  and  had  no  recollection  of  his  journey  to 
Glasgow.  Having  arrived  there,  he  identified  everyone  he 
met  as  someone  he  had  known  before,  and  called  the  asylum 
Dunrobin  Castle,  being  still  under  the  impression  he  had 
never  left  home. 

The  excitement  is  often  violent,  frequently  paroxysmal 
and  impulsive,  the  result  of  a  fresh  accession  of  hallucinations. 
Sleeplessness  is  naturally  a  symptom  as  long  as  the  excite- 
ment lasts,  and  suicidal  attempts  are  common  either  from 
fear  in  the  acute  stage,  or  from  the  acute  depression  which 
follows  as  a  stage  of  reaction.  One  must  be  very  careful 
not  to  trust  such  a  patient  too  soon,  even  though  he  may 
seem  'to  be  clothed  and  in  his  right  mind,'  for  there  is  an 
ebb  and  flow  of  depression  for  a  few  days  at  least  in  many 
cases. 

The  bodily  health  is  often  below  par  from  neglect,  want 
of  food,  visceral  disorder  the  result  of  indulgence,  and  ex- 


286  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

posure.  Not  a  few  cases  die  of  pneumonia,  many  take  long 
to  recover  from  gastro-hepatic  disorder,  and  a  large  number 
suffer  from  constipation.  The  temperature  is  above  normal, 
and  the  pulse  is  rapid. 

Acute  Alcoholic  Mania. — This  form  is  usually  seen  in  cases 
naturallv  predisposed  to  insanity,  it  is  less  delirious,  and  less 
oblivious  in  its  character.  It  may  be  seen  in  those  likely  to 
be  attacked  during  adolescence,  the  climacteric  or  senile 
stage  of  life,  or  at  any  time  when  unfavourable  conditions 
of  bodil}-  health  prevail. 

The  symptoms  are  graded  in  all  degrees,  from  an  attack 
resembling  delirium  tremens  to  an  attack  resembling  typical 
acute  mania.  Tremor  may  be  present  to  some  extent, 
but  it  usually  disappears  early,  the  maniacal  symptoms  still 
persisting.  Hallucinations  of  hearing  are  more  common 
than  those  of  sight,  fear  is  less  accentuated,  and  the  excite- 
ment has  a  more  evident  relation  to  things  that  are.  Delu- 
sions of  suspicion  and  persecution  are  often  evident,  and  the 
natural  emotions  may  be  perverted.  The  patient's  conscious- 
ness of  himself,  his  surroundings,  and  the  lapse  of  time  may 
be  quite  intact.  The  mania  may  be  characterized  by  good 
humour,  restlessness,  and  fun,  or- by  sullen,  angry  speech  and 
outbreaks. 

The  physical  condition  is  generally  fairly  good,  and  this 
is  evidence  that  the  brain  is  itself  unstable,  requiring  no 
pathogenic  aid  from  the  bodily  organs.  Cases,  however, 
do  frequently  occur  which  manifest  minor  disorders,  and 
it  is  safe  in  all  alcoholic  cases  to  strictly  examine  the  state  of 
the  alimentary  system  and  the  condition  of  the  bowels. 

The  Prognosis  in  these  two  forms  of  alcoholic  insanity  is 
good,  for  the  agent  is  usually  expelled  without  doing  serious 
structural  damage,  and  the  chief  risk  in  delirium  tremens  is 
death  from  exhaustion  or  intercurrent  disease.  In  acute 
alcoholic  mania  the  proportion  of  mental  recoveries  is  less, 
perhaps  only  slightly  so,  but  the  risk  of  death  is  not  so  great. 
Many  cases  of  this  kind  are  liable  to  become  chronic,  if  the 
indulgence  in  alcohol  is  again  and  again  resumed. 

The  Treatment  is  determined  by  the  case.  As  a  general 
rule,  a  purgative  is    desirable,  diluent  drinks  to  flush  the 


ALCOHOLIC  INSANITY  287 


kidneys  and  keep  the  skin  active.  Oatmeal  gruel  is  often 
very  helpful  in  the  directions  indicated,  and  so  is  beef-tea. 
After  a  long  experience  of  such  cases,  I  find  that,  in  addition 
to  the  above,  little  more  than  expectant  treatment  is  required, 
except  where  we  recognise  intercurrent  symptoms.  These 
we  must  treat,  and  we  must  also  be  quick  to  guard  against 
accidents,  suicide,  or  homicide,  and  be  careful  to  feed  the 
patient  according  to  his  digestive  capacity.  Some  cases 
remain  in  a  subacute  state  after  the  acute  symptoms  have 
passed  off,  for  a  long  time,  and  threaten  to  pass  into  the 
chronic  phase  of  the  disease.  A  careful  scrutiny  of  their 
bodily  health  and  habits  may  reveal  a  hitherto  hidden  weak- 
ness of  organic  function  which  has  so  far  baffled  the  observer 
and  retarded  convalescence.  The  best  example  of  this  is  in 
gastric  disorder,  and  though  the  patient  may  not  refuse  food 
absolutely,  he  may  take  a  small  quantity.  For  some  of  these 
the  infusion  or  extract  of  condurango  is  indicated,  and  if  it 
fails,  especially  in  cases  refusing  food,  large  doses  of  bismuth 
may  be  tried  with  success. 

Dipsomania  is  a  term  applied  to  that  intense,  irresistible 
craving  for  stimulants  which  is  usually  periodical,  but  not 
necessarily  so.  The  distinction  drawn  by  Sibbald  between 
it  and  other  forms  of  alcoholic  insanity  is  that  here  we  have 
a  symptom,  not  a  primary  cause  of  disease.  It  occurs  in 
all  sorts  and  conditions  of  men  and  women,  and  at  all  ages. 
The  worst  cases  are  those  which  begin  at  puberty  and 
adolescence,  and  women  at  the  climacteric,  and  the  most 
hopeful  are  those  which  have  had  a  physical  cause,  such  as 
injury  or  ill-health.  When  free  from  the  spell,  there  may 
be  little  or  no  evidence  of  intellectual  failure  ;  but  the  moral 
character  is  certainly  degraded  in  fully-established  examples 
of  dipsomania.  Some  cases  not  too  deeply  tainted  may 
repent  and  make  more  or  less  successful  attempts  at  reform  ; 
but  it  may  be  taken  as  a  general  rule  that  the  course  is 
retrograde  morally,  mentally,  and  physically.  The  typical 
dipsomaniac  is  an  unprincipled  liar,  cunning  and  deceitful. 
He  is  as  plausible  a  man  as  you  will  meet,  and  when  free 
from  drink  a  social  factor  of  some  importance  to  those  who 
know  him  not.     He  is  a  moral  reprobate,  and  therefore  a 


288  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

man  who  is  restrained  by  no  sense  of  honour  or  moral  obh- 
gation  whatever.  Not  even  regard  for  law  or  public  opinion 
— in  other  words,  self-interest — has  any  weight  in  the  balance 
against  his  strong  craving  impulses.  It  must  not  be  sup- 
posed that  many  such  men  and  women  have  not  made  good 
starts  in  life.  Some,  indeed,  have  been  most  estimable  in 
their  life  and  character,  kind  and  helpful  to  others,  generous 
to  a  fault,  and  the  breakdown  of  such  men  and  women  is 
one  of  the  saddest  pictures  of  everyday  life.  It  is  gratifying 
to  know,  however,  that  not  a  few  are  safely  guided  by  their 
friends  through  their  declining  years,  the  craving  paroxysms 
practically  dead ;  and  though  the  memories  are  sad,  self- 
respect  has  in  great  measure  been  regained. 

Chronic  Alcoholic  Insanity. — Of  many  of  those  who  come 
under  this  class,  it  may  be  said  that  they  have  become 
altered  personalities  in  the  true  sense  of  the  term.  The 
sum  total  of  the  man  is  changed,  and  he  views  his  environ- 
ment with  suspicion  and  altered  perception.  The  chronic 
state  is  either  a  sequel  to  acute  alcoholic  insanity,  or  a 
gradual  result  of  prolonged  imbibing  without  necessarily 
being  incapable.  It  should  be  distinguished  from  chronic 
alcoholism,  which  may  never  end  in  active  insanity,  though 
it  may,  and  usually  does,  terminate  in  degeneration  of  mind 
and  nervous  system. 

In  chronic  alcoholic  insanity  the  most  frequent  and 
prominent  features  are  : 

I.  Hallucinations  of  hearing,  sometimes  of  touch  or  taste, 
and  more  rarely  of  sight.  These  hallucinations  may  be  due 
to  alterations  in  special  centres,  or  may  arise  in  the  case  of 
hearing  from  thought  echoes.  Voices  are  heard  often  accusing 
the  man  himself,  or  reproaching  his  wife,  or  suggesting  her 
unfaithfulness.  The  hallucinations  of  hearing  are  not  of  a 
pleasant  character,  and  they  accentuate  suspicions  of  con- 
spiracy, persecution,  and  malevolence  on  the  part  of  others. 
The  other  senses  may  be  perverted  so  that  suspicion  of 
poisoning  may  arise,  or  ideas  of  mysterious  electrical  agency 
affecting  the  whole  system. 

■   2.  Morbid  suspicion  is  the  predominant  feeling.     The  man 
cannot  help  it,  suspicion  is  ingrained  in  his  nature — it  may 


ALCOHOLIC  INSANITY 


be  a  gradual  evolution  of  years  altering  his  whole  character 
— and  every  word  and  action  is  misconstrued.  This  state  of 
suspicion  has  rendered  him  solitary  and  moody,  and  some- 
times irritable  and  dangerous. 

3.  Altered  Adjustment  to  the  Environment. — As  a  result  of 
the  prolonged  toxic  influence  insidiously  acting  on  a  nervous 
system  which  eventually  undergoes  material  change,  exces- 
sive sensibility  in  one  direction  and  diminished  sensibility  in 
another  give  rise  to  altered  reactions.  Normal  perception 
has  ceased  in  relation  to  many  stimulations,  though  a  man 
may  still  recognise  differences  in  temperature,  appreciate 
musical  qualities,  and  engage  in  conversation  correctly  so 
far  as  language  is  concerned.  There  is,  all  this  notwith- 
standing, an  undercurrent  of  morbid  sensation,  giving  rise  to 
mysterious  suggestions  which,  operating  on  a  suspicious 
nature,  colour  the  whole  emotional  life  and  intellectual 
character  of  the  man.  In  this  way,  to  use  a  popular  phrase, 
'  he  sees  everything  through  green  spectacles,'  'with  jaundiced 
eyes,'  and  thus  adjusts  himself  anew  and  in  a  morbid  sense 
to  his  environment.  The  environment  is  all  right ;  it  is  the 
man  who  is  wrong. 

4.  Delusions. — These  are  founded  on  suspicion  and  dis- 
trust, and  any  aversion  of  the  past,  whether  pre-alcoholic  or 
not,  is  sufficient  to  propagate  delusions  regarding  particular 
persons.  A  man  so  affected  cannot  conceive  of  any  friendly 
purpose  in  anything  that  is  done  for  him.  If  he  refuses  food 
and  requires  to  be  fed,  the  stomach-tube  is  to  convey  poison, 
and  the  gag  is  to  destroy  his  teeth.  He  thinks  people  are 
looking  at  him  and  making  private  comments  regarding  him. 
He  may  be  a  prey  to  hypochondriacal  delusions,  especially 
at  the  climacteric  period ;  he  often  has  delusions  of  identity, 
and  of  a  sexual  character,  e.g.,  regarding  the  malevolence 
of  women  working  his  ruin  —  delusions  which  somewhat 
resemble  the  delusions  of  many  masturbators,  and  may  in 
both  cases  have  a  genesis  in  the  sexual  centres. 

It  must  not  be  supposed  that  the  above  general  outline 
will  include  all  cases  of  chronic  alcoholic  insanity.  There 
are  deviations  according  to  personal  differences  of  suscepti- 
bility and  character,  and  there  may  be  cases  that  show  some 

19 


290  CLINICAL  MANUAL  OF  MENTAL  DISEASES 


amelioration  under  treatment.     The  suicidal  element,  though 

less  prevalent  in  the  chronic  form,  is  always  potential  if 
hallucinations  of  hearing  are  acute  and  distressing ;  but  the 
homicidal  impulse  is  more  frequent,  and  wife  and  children 
and  dearest  friends  may  be  the  victims.  The  homicidal 
impulse  may  be  sudden  and  follow  a  true  aura  {vide  clinical 
case  M.  C).  Some  of  the  symptoms  here  described  show 
how  nearly  in  character  this  type  encroaches  on,  and  some- 
times overlaps,  other  forms — chronic  progressive  delusional, 
climacteric,  and  masturbational  insanity  ;  but  from  the  first 
of  these  it  may  often  be  distinguished  by  the  sullen,  un- 
sociable, aggressive  character  of  the  alcoholic  form,  by  the 
fact  that  the  delusions  are  less  systematized,  and  not  pro- 
gressive, although  they  are  often  fixed ;  and  by  other 
characters  {vide  chapter  on  '  Chronic  Progressive  Insanity  ')• 
It  is  true,  as  already  said,  that  the  two  may  be  combined. 
Regarding  the  other  forms  mentioned,  it  may  be  found  that 
the  climacteric  has  a  history  of  alcoholic  excess  of  long 
standing,  but  more  often  the  alcoholic  excess  comes  as  a 
craving  of  that  period  de  novo,  and  for  masturbational  in- 
sanity the  age  and  absence  of  alcoholic  histor}^  is  sufficient 
to  determiine  the  diagnosis. 

Alcoholic  Dementia  or  Degeneration. — This  is  a  condition 
often  confounded  wuth  general  paralysis,  and  when  alcoholic 
excess  operating  on  a  morbidly  plastic  nervous  system  does 
produce  general  paralysis,  there  is  nothing  to  choose  between 
the  two  terms  if  marked  mental  degeneration  is  evident  at  the 
outset.  One  case  at  present  in  hospital,  and  included  in 
the  clinical  illustrations,  has  rendered  distinction  between 
the  two  very  difficult. 

The  signs  being  chiefly  negative,  you  will  find  various 
degrees  of  mental  degeneration,  which,  because  of  their 
negative  character,  because  of  the  inoffensiveness  of  the 
individual,  and  because  of  the  difficulty  of  obtaining  tangible 
evidence  on  the  subject,  render  a  diagnosis  of  technical 
insanity  impossible.  The  drinking  habits  do  not  constitute 
insanity,  neither  does  the  neglect  of  moral  obligations,  nor 
the  failure  of  memory. 

A  stage  however   is  reached,    when    his  more  enfeebled 


ALCOHOLIC  INSANITY  291 

memory  and  perception,  his  slowness  and  dulness  of  intellect, 
his  incapacity  for  business,  and  his  general  apathy,  call  for 
interference  with  his  liberty,  and  then  it  may  be  possible  to 
certify  the  man  insane. 

The  nervous  signs  may  be  well  marked,  or  they  may 
appear  slowly ;  and  according  to  the  particular  site  selection 
of  the  alcoholic  poison,  they  give  evidence  of  its  activity  in 
some  locality  or  other.  In  one  case  you  find  facial  tremors 
and  affection  of  speech,  with  or  without  pupillary  symptoms  ; 
in  others  the  first  weakness  may  be  found  in  the  lower 
extremities — a  paresis  usually — or  it  may  be  a  want  of 
co-ordination  of  finer  movements  in  the  muscles  of  the 
hand. 

The  prognosis  and  treatment  of  the  last  two  forms  of 
alcoholic  insanity  cannot  be  spoken  of  very  hopefully. 
Recognising  that  various  degrees  of  alcoholic  poisoning  are 
possible,  the  volatile  character  of  the  agent  which  produces 
this  mischief,  and  the  chance  that  you  may  regard  symptoms 
as  organic  which  are  still  functional,  a  prognosis  should  be 
carefully  hedged.  It  may  be  that  only  slight  improvement 
is  possible  when  alcohol  has  been  withdrawn,  but  that  may 
be  enough  to  bring  the  patient  back  to  a  pre-borderland 
stage. 

Treatment  should  consist  of  either  absolute  prohibition,  or 
in  particular  cases,  where  medical  men  are  satisfied  that  the 
exigencies  of  the  case  require  it,  moderate  doses  under 
restriction  and  discipline.  Everything  should  be  done  for 
the  general  health,  and  in  the  treatment  of  particular  bodily 
symptoms,  that  can  be  thought  of.  It  is  astonishing  how 
men  sometimes  recover — at  least  for  a  time — losing  their 
demented  appearance,  recovering  a  brightness  of  eyes  and 
expression,  and  showing  little  evidence  of  those  motor  dis- 
orders that  seemed  likely  to  be  permanent.  That  mischief 
irreparable  has  been  done  is  true,  but  a  functional  improve- 
ment has  taken  place,  and  only  evidences  of  an  organic 
residuum  remain.  These  may  consist  of  a  drooping  of  a 
corner  of  the  mouth,  a  slurring  of  certain  letters  in  speech, 
a  slowness  and  carefulness  of  locomotion,  or  a  feebleness 
of  manipulation. 

iq — 2 


292  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

Opium  and  other  Medicinal  Stimulants. 

While  alcohol  is  the  most  general  intoxicant  and  narcotic 
in  use,  it  is  b}^  no  means  the  only  one,  and  medical  men  in 
general  practice  have  in  their  wide  experience  of  men  and 
women  met  with  strange  instances  of  nervous  cravings  for 
stimulants  other  than  alcohol.  The  nervous  condition  which 
excites  this  craving  is  not  yet  understood,  nor  is  it  a  true 
solution  of  the  problem  to  say  that  uncontrollable  thirst  is 
the  real  explanation.  A  man  is  thirsty,  and  may  prefer  a 
certain  drink  which  is  not  alcoholic  ;  but  when  he  selects  a 
drink  containing  an  ingredient,  or  ingredients,  which  have  a 
selective  affinity  for  vaso-motor  centres,  or  other  centres  of 
the  nervous  system,  and  thus  increase  his  sense  of  well- 
being,  the  explanation  must  be  much  more  complex.  More- 
over, why  is  it  that  some  women  will  eat  dry  tea,  and  the 
natives  of  Paraguay  and  Brazil  eat  coca  leaves,  apart  from 
their  use  as  strength  sustainers  ?  Why,  also,  do  men  chew 
tobacco  ?  Thirst  is  usually  a  factor  where  there  is  exposure 
to  great  heat  and  perspiration  is  profuse. 

Whatever  the  explanation  may  be  the  fact  remains,  that 
people  resort  now  more  than  ever  to  the  indulgence  in  drugs 
charged  with  stimulant  and  narcotic  properties.  As  a  result 
of  overwork,  anxiety,  and  mental  strain,  this  indulgence  may 
first  have  seemed  right  and  proper,  but  a  snare  the  most 
insidious  is  here  often  unwittingly  set  for  the  unwary,  and 
the  medical  profession  is  now  only  realizing  the  fact  that  it 
is  not  quite  free  of  reproach  in  this  respect.  Moreover, 
medical  men  themselves,  because  of  their  very  familiarity 
with  such  drugs,  are  apt  to  challenge  results  which  are 
not  infrequently  disastrous. 

Two  motives  can  be  adduced  for  this  craving :  one  is 
sensual ;  the  other  is  to  obtain  more  or  less  oblivion  from 
pain,  mental  distress,  or  a  state  of  wakefulness.  The  drug 
most  commonly  in,  use  is  opium,  and  it  is  much  more 
generally  purchased  without  medical  prescription  than  many 
suppose.  Into  the  vexed  question  of  the  moral  and  social 
evils  of  opium  we  need  not  enter.  De  Quincey's  talk  and 
writings  furnish  a  brilliant  example  of  the  mental  creations 


OPIUM  INEBRIETY  293 

possible  under  its  influence,  and  as  a  brain  stimulant  it  is 
greater  than  alcohol,  and  more  sustaining  in  its  effects. 
Nevertheless,  cases  are  not  infrequent  where  it  has  altered 
the  whole  character — changed  the  personality  more  surely 
than  alcohol ;  and  it  is  when  this  baneful  influence  is 
manifest  that  medical  attention  is  called  to  it,  and  often 
too  late. 

The  first  effect  produced  by  opium  is  a  gradual  sense  of 
exhilaration  and  mental  activity  without  any  consciousness 
of  mental  effort.  By  means  of  conversation  or  the  mental 
stimulus  of  work  this  may  be  kept  up  for  some  time,  and 
then  sleep  is  impossible,  and  a  state  of  delirium  may  be 
induced  which  will  soon  subside,  except  in  very  susceptible 
persons.  In  a  few  cases  sexual  or  other  impulses  may  be 
quickened,  but  if  the  individual  from  the  first  allows  him- 
self to  be  mentally  passive  and  subjective,  a  stage  of  torpor 
ensues,  the  intensity  of  which  is  according  to  the  dose  and 
susceptibility  of  the  patient. 

In  the  case  of  the  habitue,  the  wakening  up  is  as  terrible  as 
the  coming  back  to  life  of  a  drowned  man  ;  the  diminution 
of  mental  well-being  is  most  intense,  and  nothing  will  satisfy 
the  poor  unfortunate  but  a  repetition  of  the  dose.  He  will 
beg,  borrow,  or  steal,  and  lie  without  flinching,  to  get  at  the 
supply  which  is  to  him  as  the  very  breath  of  heaven. 

Opium  differs  from  alcohol  in  this,  that  it  does  not  affect 
the  motor  nervous  system,  and  that  its  potency  is  more 
persistent,  its  hold  on  the  nervous  system  more  enduring, 
than  in  the  case  of  alcoholic  indulgence.  It  is  said  by 
Norman  Kerr  that  other  differences  are  quite  noticeable ; 
thus,  opium  inebriety  is  more  functional  than  organic,  more 
solitary  in  its  gratification,  more  soothing  in  its  mental 
effect,  but  more  difficult  to  restrain.  Opium  raises  the 
temperature  ;  alcohol  lowers  it.  That  female  opium  inebriates 
are  rare  is  a  statement  of  Norman  Kerr's  which  must  be 
regarded  with  some  doubt,  and  the  experience  of  many 
apothecaries  will  confirm  our  doubts. 

I  need  not  go  further  into  this  subject,  but  simply  cata- 
logue a  few  more  inebriants  in  use.  These  are  chloral, 
chloroform,  cocaine,  and  other  drugs  which  have  a  stimu- 


294  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

lating  or  soporific  effect,  and  they  usually  have  both  com- 
bined, first  stimulating,  then  depressing. 

The  question  of  the  civil  treatment  of  such  cases,  of 
legalized  restraint,  is  one  which  we  need  not  waste  time 
over.  It  has  been  so  fully  threshed  out,  and  the  consensus 
of  medical  opinion  is  so  strongly  in  favour  of  more  drastic 
legislation,  that  all  that  can  be  done  is  to  wait  for  the 
psychological  moment  when  circumstances  will  force  the 
question  into  the  domain  of  practical  politics. 

In  the  last  chapter  of  this  work,  on  certification  of  the  insane 
and  other  matters,  information  will  be  found  regarding  special 
homes  for  inebriates,  and  instructions  for  their  admission. 

Syphilitic  Insanity. 

Regis,  who  quotes  the  views  of  many  authors  on  this 
subject,  says  that  '  the  predominant  opinion  is  that  syphilis 
may  in  certain  cases  cause  or  favour  the  appearance  of 
insanity,  but  that  insanity  thus  produced  does  not  pre- 
sent any  special  characters ;  and  that  there  is  no  syphilitic 
insanity  properly  so  called.  Generally,  moreover,  syphilis 
does  not  act  alone  in  these  cases,  and  there  is  almost  always 
hereditary  predisposition,  and  other  occasional  causes.' 

This  view,  supported  by  strong  general  testimony,  cannot 
be  disputed.  The  value  of  the  syphilis  equation  is  an  un- 
known quantity  even  when  the  syphilitic  history  is  unmis- 
takable, and  when  the  still  more  definite  assurance  of  post- 
mortem demonstration  is  produced. 

The  prevalence  of  this  type  of  insanity  is  reckoned  differ- 
ently in  different  countries,  so  that  discrepancies  are  great, 
and  some  confusion  is  the  result.  Clouston  finds  only  one- 
half  per  cent,  of  all  his  cases  so  affected,  while  other  authorities 
of  eminence  in  London  and  abroad  speak  of  syphilis  as  a 
factor  of  much  more  serious  importance.  The  diagnosis  of 
a  syphilitic  history  is  not  by  any  means  an  easy  matter  in 
a  large  proportion  of  cases,  and  that  may  account  partly  for 
the  discrepancy ;  but  it  is  probably  due  in  a  higher  ratio  to 
the  fact  that  a  great  city  like  London  will  prove  a  hotbed  of 
syphilitic  disease  out  of  all  proportion  to  its  size,  and  out  of 
all  reasonable  comparison  with  other  centres. 


SYPHILITIC  INSANITY.  295 


For  a  very  excellent  restmte  of  the  subject  I  cannot  do 
better  than  refer  the  reader  to  the  report  of  a  discussion  on 
syphilis  in  relation  to  insanity  in  Section  XVII.  of  the 
Report  of  the  Ninth  International  Medical  Congress  held  at 
Washington  in  1887.  The  views  of  such  authorities  as 
Savage,  Hurd,  Shuttleworth,  Fletcher  Beach,  Brush, 
Wiglesworth,  Spitzka,  Godding,  and  others,  are  there  well 
put  forth. 

Admitting  as  correct  the  statement  already  given,  that 
S3^philitic  insanity  is  a  conventional  rather  than  a  scientific 
term,  it  is  still  worth  while  trying  to  classify  such  symptoms 
of  mental  derangement  as  have  been  observed,  so  as  to  focus 
some  practical  conception  of  the  disease  in  our  minds, 
Clouston  recognises  four  groups  :  (i)  Secondary  syphilitic 
insanity,  occurring  during  the  second  stage  of  the  disease, 
coincident  with  the  eruption — curable  and  rare  ;  (2)  de- 
lusional syphilitic  insanity,  supposed  by  Clouston  to  be  due 
to  shght  brain  starvation  and  syphilitic  arteritis  that  has 
become  arrested ;  (3)  vascular  syphilitic  insanity ;  and  (4) 
syphilomatous  insanity.  There  seems  no  valid  reason  why 
the  two  last  should  not  be  grouped  together,  for  though 
pathologically  different  in  their  organic  distribution,  their 
mental  effects  cannot  be  differentiated.  The  second  may  be 
accepted  clinically,  but  the  pathological  explanation,  though 
perhaps  helpful,  may  only  explain  some  cases.  The  first 
group  excludes  cases  of  insanity  associated  with  acute 
syphilis. 

It  may  be  taken  as  correct  that  the  following  arrangement 
represents  the  views  of  many  observers  :  (i)  Primary,  a  rare 
group  in  which  acute  syphilis  is  the  chief  cause  ;  (2)  secondary 
syphilitic  insanity,  with  onset  of  secondary  symptoms — corre- 
sponding to  Clouston's  first  group  ;  (3)  delusional  syphilitic 
insanity,  with  or  without  evidence  of  syphilitic  brain  lesion  ; 
(4)  insanity  associated  with  syphilitic  brain  lesion. 

I.  Insanity  associated  with  acute  syphilis  is  illustrated  in  a 
case  described  by  Wiglesworth  in  the  resume  above  referred 
to.  It  was  that  of  a  young  married  woman  only  four  months 
married,  who  was  admitted  into  Rainhill  Asylum  suffering 
from  an  indurated  chancre  of  one  labium.     She  was  dull. 


296  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

melancholy,  and  rarely  spoke.  She  resisted  everything 
strongly — not  merely  being  examined,  but  being  washed, 
changed,  etc.  After  six  weeks  she  improved,  but  afterwards 
died  from  erysipelas.  The  connection  of  the  insanity  with 
syphilis,  as  Wiglesworth  observes,  was  probably  twofold — 
physical  and  moral — and  there  was  nothing  in  the  mental 
symptoms  to  suggest  anything  but  '  resistive  melancholia.' 

It  must  also  be  remembered  that  any  case  of  this  kind 
coming  under  notice  may  be  partly  due  to  alcoholic  excess 
or  hereditary  defect,  or  the  syphilis  may  be  secondary  to 
mental  disease  now  fully  developed  for  the  first  time,  and 
not  hitherto  suspected. 

II.  Insanity  with  Onset  of  Secondary  Symptoms. — This  form 
is  not  quite  so  rare  as  the  preceding,  and  appears  to  partake 
often  of  the  character  of  a  febrile  delirium  subsiding  with 
the  disappearance  of  the  secondary  symptoms.  One  curious 
and  instructive  condition  referred  to  by  Spitzka  and  Brush, 
was  the  discover}^  made  by  Finger,  that  during  the  roseola 
eruption  there  is  abolition  of  the  knee-jerk,  reappearance 
with  the  remission  of  the  fever,  and  again  disappearance. 
Clouston  quotes  a  case  of  acute  maniacal  delirium  described 
by  Cadell  {Journal  of  Mental  Science,  vol.  xx.,  p.  564)  :  '  A 
squamous  S3-philide  appeared  in  April,  and  along  with  it 
marked  mental  excitement,  and  an  extreme  amount  of  motor 
restlessness,  this  maniacal  state  reaching  its  height  in 
August  and  September,  and  then  almost  amounting  to 
delirium.'  Coincident  with  the  disappearance  of  the 
sj'philide  mental  recovery  was  established. 

Savage  describes  the  course  of  the  disease  in  a  jockey  who 
as  a  trainer  had  a  heavy  responsibility,  and  was  an  extremely 
anxious  man :  'He  contracted  syphilis,  and  five  or  six 
months  after  the  development  of  it  got  double  optic  neuritis. 
.  .  .  He  saw  vaguely  and  with  uncertainty,  and  this  added 
to  his  suspicions,  so  that  he  thought  everyone  who  came 
near  him  was  coming  with  the  idea  of  injuring  or  tampering 
with  him  in  some  way.  He  became  pugilistic,  knocked 
people  about,  and  had  to  be  sent  to  the  asylum,  where  specific 
treatment  cured  him  rapidly.'  This  case  can  scarcely  be 
classed  as  maniacal  delirium,   for  there  was  a  groundwork 


SYPHILITIC  INSANITY  297 

of  strong  suspicion  which  gave  a  persistent  character  to  the 
mental  symptoms, 

///.  Dehisional  Syphilitic  Insanity,  with  or  without  Evidence 
of  Brain  Lesion. — This  form  is  more  common,  but  its  symp- 
toms will  suggest  to  many  something  closely  resembling 
chronic  alcoholic  insanity.  That  alcoholic  excess  and  syphilis 
are  closely  related  as  sequences  in  a  large  number  of  cases 
is  a  fact  beyond  question,  and  the  delusions  associated 
with  syphilitic  insanity  may  be  due  to  the  alcoholic  poison 
in  some  cases  at  least. 

The  fact  that  insane  suspicion,  delusions  of  persecution, 
and  the  mysterious  workings  of  unseen  agencies,  are  preva- 
lent in  men  and  women  who  have  lived  lives  of  a  most 
temperate  character  in  all  respects,  leads  to  the  conclusion 
that  the  condition  of  brain  which  underlies  this  mental 
departure  is  not  directly  related  to  toxaemia,  but  more 
probably  to  malnutrition  as  a  secondary  result  of  other 
pathogenic  conditions  as  well  as  toxccmia. 

It  is,  however,  a  remarkable  fact  that  suspicion  in  the 
case  of  delusional  syphilitic  insanity  is  often  the  ground- 
work of  the  whole  mental  aberration,  and  it  is  the  logical 
though  morbid  outcome  of  the  previous  manner  of  life  and 
mental  impressions  of  the  individual.  In  some  cases  halluci- 
nations of  hearing  are  very  troublesome,  and  feed  and 
aggravate  suspicion  to  an  alarming  extent.  Systematized 
delusions  are  often  generated  from  this  morbid  state  of 
mind — delusions  that  electric  machinery  has  been  devised 
to  work  from  a  given  point  upon  the  patient's  system ;  that 
a  conspiracy  is  formed  to  accomplish  his  disgrace  and  ever- 
lasting punishment ;  that  voices  are  heard  through  a 
phonograph,  and  come  out  through  the  pores  of  the  skin, 
and  this  is  done  by  a  young  woman  to  effect  his  destruction. 
These  are  but  a  few  of  the  delusions  that  might  be  tran- 
scribed from  the  case-books.  Mental  symptoms  may  be 
present  as  the  moral  effect  of  syphilis,  and  not  as  a  toxic  or 
degenerative  result.  Considering  all  things,  one  is  not  sur- 
prised that  the  fact  of  this  loathsome  disease  having  settled 
down  upon  one's  internal  economy  should  be  a  great  moral 
shock  of  itself,   and  induce  morbid  reflection,  melancholy, 


298  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

and  hypochondriasis.  Nor  is  it  surprising  that  out  of  this 
should  develop  systematically  delusions  of  unworthiness,  and 
of  uncleanness,  which  then  go  a  step  further  to  delusions  of 
being  contagious,  till  the  final  idea  is  fixed  and  dominant, 
that  they  communicate  by  the  breath  and  exhalations  of 
the  skin  a  deadly  poison,  necessitating  frequent  ablation  and 
depurative  treatment.  This  becomes  a  veritable  syphilo- 
phobia  in  those  already  infected,  who  dread  that  they  may 
affect  others. 

IV.  Insanity  associated  with  Syphilitic  Brain  Lesion. — The 
nervous  phenomena  are  here  most  in  evidence,  though  it 
must  not  be  forgotten  that  they  may  be  present  in  the 
delusional  type,  and  at  least  in  the  form  of  optic  neuritis  in 
the  insanity  of  secondary  syphilitis.  Here,  however,  we 
have  nervous  phenomena  in  a  profusion  of  varieties  ;  indeed, 
there  is  nothing  to  suggest  a  family  resemblance  in  the  forms 
of  nervous  disease  associated  with  the  syphilitic  constitution, 
and  the  mental  sequels  are  scarcely  less  divergent  in  their 
general  characters. 

The  syphilitic  nerve  lesions  may  be  trivial,  and  the  local 
paralyses  of  very  limited  distribution.  Ptosis,  strabismus 
or  cephalalgia  may  be  the  only  symptoms  ;  but  the  range  of 
possible  nerve  lesions  is  co-extensive  with  the  nervous 
system,  although  the  essential  nerve  elements  themselves 
are  only  affected  secondarily.  It  may  suffice  to  add  that 
tremor,  epilepsy,  paralysis  in  great  or  limited  distribution, 
are  often  the  most  striking  features  of  such  cases,  and  that 
the  mental  symptoms  are  various.  The  relation  of  syphilis 
to  general  paralysis  has  been  already  discussed ;  but  the 
symptoms  may  closely  resemble  the  symptoms  of  general 
paralysis,  and  yet  the  syphilitic  lesion  be  the  essential 
feature,  and  its  outward  evidence  the  predominant  indication 
in  the  case. 

The  so-called  pseudo-general  paralysis  of  syphilitic  origin 
may  in  its  inception  and  early  development  closely  resemble 
general  paralysis  in  the  mental  expansive  delirium  and 
exaltation,  in  defects  of  co-ordination  of  thought,  speech  and 
writing.  In  a  case  quite  recently  under  treatment,  the  corre- 
spondence in  many  details  between  the  two  was  most  re- 


DELIRIUM  TREMENS— CLINICAL  ILLUSTRATIONS     299 

markable,  but  the  appearance  of  ptosis,  premature  baldness, 
and  the  history  of  the  case,  raised  a  suspicion  of  syphiHs, 
which  was  afterwards  confirmed.  Anti-syphihtic  treatment 
(iodide  of  potassium  internally,  and  mercurial  inunction  of 
the  scalp)  was  quickly  followed  by  rapid  cessation  of  the 
mental  symptoms.  The  man  is  now  a  hopeless  hemiplegic, 
but  except  for  some  mental  failure  he  is  able  to  occupy  a 
position  in  society — a  back  seat,  so  to  speak — yet  a  position 
which  may  be  stationary  for  some  years  to  come. 

The  mental  condition  may  be  one  of  lethargy  and  failure 
of  mental  power.  It  may  be  one  of  active  insanity  in  spurts, 
or  in  a  recurrent  form  it  may  show  itself  from  time  to  time, 
and  recovery  still  be  possible.  There  is  no  special  type, 
but  the  tendency  is  to  dementia. 

The  prognosis  is  fair,  and  in  the  first  and  second  forms 
described,  is  decidedly  so.  Many  cases  recover  that,  judging 
merely  by  the  extent  of  paralysis  without  reference  to  its 
cause,  are  unfavourable,  but  they  are  never  quite  the  same 
men  after.  Where  mental  enfeeblement  is  a  marked  feature, 
the  prognosis  is  not  so  good. 

The  treatment  is  the  usual  anti-syphilitic  treatment,  atten- 
tion to  the  state  of  the  general  health,  the  rules  of  hygiene, 
and  the  exercise  of  moral  discipline  and  self-restraint. 

Clinical  Illustrations, 

Delirium  tremens,  with  the  popular  description  of  which  we 
are  all  familiar,  is  not  the  form  that  usually  reaches  asylums. 
Such  cases  more  often  are  treated  in  special  side-rooms  of 
general  hospitals  or  workhouses,  and  the  two  following 
summaries  are  taken  from  notes  of  private  practice. 

/.  Delirium  Tremens  with  Hallucinations  of  Sight  and  Hearing  ; 
Vivid  Panorama  of  Hallucinations  of  Sight;  Hallucina- 
tions of  Hearing  and  Smell ;  Extreme  Exhaustion ;  Re- 
covery. 

This  was  the  case  of  a  gentleman,  aged  38,  who  was  in  a 
strange  delirious  state  for  several  days.  He  had  been  drink- 
ing on  a  small  scale  for  a  number  of  years,  but  three  months 
previous  to  the  attack   he  had  been   drinking  whisky  like 


300  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

water,  disposing  of  several  bottles  in  twenty-four  hours. 
For  five  days  and  nights  he  did  not  sleep.  He  was  dis- 
tracted by  the  panorama  of  scenes  that  passed  before  him. 
He  saw  a  man  enclosed  by  wire  netting  in  a  kind  of  cage, 
with  his  person  exposed ;  then  came  a  procession  of  women, 
one  by  one,  headed  by  the  patient's  wife.  Then  his  wife  in 
reality  came  into  the  room,  and  he  called  her  the  blackest 
names  possible,  for  so  debasing  herself  as  to  go  near  the  man 
in  the  netting.  The  next  scene  was  in  Paris  in  one  of  the 
cafes-chantant,  where  he  saw  his  own  wife  with  other  women 
in  a  semi-nude  state,  conducting  themselves  in  an  abandoned, 
indecently  suggestive  manner.  These  scenes  all  passed 
before  him  in  a  mirror  on  the  wall  of  his  room.  He  heard 
voices,  saw  insects  crawling  all  over  the  beds,  and  he  tried 
to  catch  them.  He  declared  he  was  sickened  by  the  smell  of 
dead  rats  in  a  corner  of  the  bed.  He  was  extremely  rest- 
less, delirious,  and  unconscious  of  his  true  position,  but  he 
had  not  forgotten  his  previous  regular  habits  of  employment. 
He  wanted  to  go  to  work  in  the  middle  of  the  night,  and 
threatened  to  jump  out  of  the  window  if  he  wasn't  allowed. 
Owing  to  his  perpetual  restlessness,  and  continually  throw- 
ing the  clothes  off,  he  got  very  cold,  and  required  hot  bottles 
applied.  The  pupils  were  dilated,  the  pulse  was  very  rapid, 
the  appetite  much  impaired,  and  death  from  exhaustion  was 
almost  imminent.  He  required  to  be  fed  very  frequently, 
with  small  quantities  at  a  time,  of  egg-custard,  beef-tea, 
semolina,  or  other  puddings.  He  had  soda-and-milk,  and 
lemon-juice  as  often  as  he  wished.  He  required  sleeping- 
draughts  and  a  medicinal  stimulant.  The  sixth  night  he 
slept  for  ten  hours  at  a  stretch,  and  wakened  in  his  right 
mind.  After  his  recovery  he  felt  an  itch  in  the  skin  all  over, 
from  the  crown  of  the  head  to  the  sole  of  the  feet.  This 
disappeared  very  soon. 

II.  Epileptiform  Seizures,  Severe  G astro-hepatic  Disorder,  Vomit- 
ing and  Purging,  Hallucinations  of  Sight,  Fierce  Craving 
for  Drink,  Violent  Excitement ;  Recovery. 

This  man,  aet.  55,  had  been  a  constant  tippler  for  thirty 
3'ears.     The  attack  began  with  epileptiform  seizures,  six  or 


ACUTE  ALCOHOLIC— CLINICAL  ILLUSTRATIONS      301 

seven  of  them  within  a  week.  He  took  two  the  first  day,  one 
on  each  of  the  following  three  days ;  an  interval  of  freedom 
followed,  and  then  they  were  repeated  in  a  milder  form. 
They  had  all  the  appearance  of  epileptic  fits,  but  there  were 
two  notable  exceptions  to  the  general  rule.  There  was  no 
warning  cry,  no  aura,  and  there  was  no  post-epileptic  coma, 
but  restlessness  immediately  followed  the  fits.  The  patient's 
appetite  began  to  fail  months  previous  to  the  attack, '  and 
when  he  came  under  treatment  there  was  much  purging 
and  vomiting  for  eight  days,  so  that  he  was  extremely  re- 
duced for  want  of  nourishment,  and  owing  to  his  excite- 
ment ;  the  vomiting  was  of  a  bilious  character ;  the  faeces 
were  dark  and  most  offensive  in  odour.  The  first  food  that 
settled  on  his  stomach  was  milk-and-soda. 

During  all  this  time  he  had  hallucinations  of  sight ;  he 
saw  men  and  women  walking  on  their  heads  constantly. 
He  was  under  the  delusion  that  he  was  in  Liverpool.  After 
the  second  day  he  became  outrageous  ;  would  tear  himself 
away  from  his  attendant  in  order  to  get  drink,  and  had  to 
be  restrained.  He  had  to  be  bundled  up  in  the  dry  pack, 
otherwise  there  would  have  been  accidents,  and  while  so 
restrained  he  was  in  a  terrible  state  of  mind,  imploring  to  be 
released ;  but  soon  this  subsided  and  he  recovered. 

III.  Acute  Alcoholic  Insanity,;  Drinking  for  a  Year ;  Delusions 
of  Persecution ;  Violent,  Dangerous ;  Various  Hallucina- 
tions and  Delusions ;  Recovery. 

T.  B.,  3et.  34.  This  man  had  been  a  very  heavy  drinker, 
and  was  known  frequently  to  drink  two  bottles  a  day,  and 
sometimes  as  many  as  three.  His  condition  before  admission 
to  the  asylum  was  much  more  excited  and  violent  than  it  was 
a  day  after  admission.  We  sometimes  find  that  there  is  a 
certain  amount  of  shock  as  the  result  of  putting  a  man  under 
restraint  in  a  place  which  is  strange  to  him.  Thereafter 
he  pulls  himself  together,  and  for  a  time  at  least  seems  to 
be  very  much  better.  On  admission  this  man  was  rather 
excited,  but  spoke  very  sensibly,  though  in  an  excited 
manner  ;  the  hands  were  tremulous,  the  face  flushed,  and  he 
was  perspiring  a  little.     The  pulse  was  120  per  minute,  full. 


302  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

and  regular.  The  tongue  was  covered  with  a  thick,  moist, 
white  fur  ;  the  pupils  were  dilated  and  fairly  active  ;  knee 
reflexes  not  active,  other  reflexes  present. 

For  the  first  three  days  his  condition  continued  much  the 
same.  He  was  rather  restless,  and  disposed  to  be  irritable. 
He  was  talkative,  and  inclined  to  pass  from  one  subject  to 
another  in  a  rather  irrelevant  way. 

On  the  afternoon  of  the  third  day  he  became  more  excited 
and  irritable,  and  in  the  evening  he  became  delirious. 
During  these  three  da3'S  he  perspired  freely  ;  he  passed  ver}" 
little  urine,  but  he  was  often  trying  to  do  so.  The  bladder 
seemed  in  an  irritable  state,  and  micturition  caused  pain. 
The  urine  was  very  high-coloured,  with  a  specific  gravity  of 
1031,  but  containing  no  albumin.  The  appetite  was  poor, 
the  stomach  extremely  irritable,  and  he  rejected  food. 

At  10  o'clock  on  the  night  of  the  third  day,  he  said  he 
would  not  come  out  of  his  bed,  as  there  were  women  in  the 
dormitory  ;  he  was  threatening  and  violent ;  he  had  to  be 
put  in  the  padded  room,  and  it  was  now  clear  that  his  mind 
was  far  astray,  and  that  he  was  under  the  influence  of 
hallucinations.  He  believed  he  was  ploughing  in  the  fields, 
and  he  ran  the  horses  up  against  the  walls  of  the  room  ;  he 
wanted  next  to  kill  a  cat  which  he  saw  in  the  room,  and  he 
declared  he  heard  people  shooting.  He  walked  about  the 
room  to  gather  the  sheep  ;  said  the  window  above  the  room 
door  was  falling,  and  sat  in  a  corner  of  the  room  to  warm 
himself  at  an  imaginary  fire.  The  perspiration  was  pouring 
over  him,  and  the  tremor  was  increased.  Two  days  later  it 
was  reported  that  he  was  much  quieter,  and  that  his  mind 
was  battling  with  confusing  ideas  as  to  who  he  was  and 
where  he  was.  He  seemed  very  much  at  sea,  declared  that 
he  was  very  tired,  which  was  probably  the  case  ;  but  he 
explained  it  as  due  to  his  '  riding  all  day  yesterday  with  the 
yeomanry.'  Perspiration  ceased,  tremors  diminished,  knee 
reflexes  slightly  exaggerated,  pulse  92,  soft  and  regular. 
Later  in  the  day  he  became  conscious,  and  realized  his 
position  and  surroundings ;  but  the  urine  was  still  high- 
coloured  and  scant)',  with  a  specific  gravity  of  1030.  The 
tremors  had  disappeared.     He  made  a  good  recovery. 


Plate  VII.— VARIOUS  TYPES. 


IMBECILITY. 


SYPHILITIC    INSANITY    (HEMIPLEGIA). 


ALCOHOLIC    DEMENTIA. 


DIOCY    (IIYDROCEI'HALIC-SYPHILITIC). 
To  face  p.  302. 


ACUTE  ALCOHOLIC— CLINICAL  ILLUSTRATIONS      303 

In  addition  to  Case  III.  the  following  four  instances  of  acute 
alcoholic  insanity  as  met  with  in  asylums  will  suffice.  There 
is  no  sharp  line  of  distinction  possible  between  the  two  cases 
of  delirium  tremens  and  Case  III.  already  given.  Of  those 
now  following,  A.  and  B.  were  male  cases  ;  C.  and  D.,  female. 

IV.  Nervous  Terrified  Expression ;  Hallucinations;  Acute 
Excitement  of  Fear. 

A.  was  a  tall,  slender,  delicate  man,  set.  32.  '  Extremely 
depressed  and  terrified  in  expression.  Hallucinations  of 
hearing.  Imagined  voices  were  charging  him  with  crime. 
He  was  restless,  agitated,  and  tremulous,  and  very  much 
alarmed,  especially  at  night  when  the  lights  were  turned 
out.'  Excitement  soon  ceased,  but  he  was  slow  in  recover- 
ing mental  vigour.     Recovered. 

V.  Previotis  Attacks ;  Mania  from  Alcoholic  Excess  ;   no  Signs 

of  it  in  Nervous  System. 

B.  '  is  an  old  stager,  has  been  insane  through  drink  several 
times,  and  his  condition  resembles  ordinary  acute  mania, 
for  it  is  free  from  delirium,  hallucinations,  or  tremor.  He 
talks  tall  and  yet  coherently,  seems  to  be  poking  fun  at  his 
doctor  and  attendants,  and  almost  suggests  rogue  rather 
than  fool.  He  says  he  is  the  man  in  the  moon,  that  Jesus 
Christ  is  coming  to  stay  with  him.  He  has  threatened 
violence,  and  a  stone  was  found  in  one  of  his  pockets  for 
the  purpose,  he  averred,  of  "splitting  their  skulls."  He  is 
insane  in  speech  as  well  as  conduct.  He  carries  in  his 
napkin  some  stones  which,  he  says,  are  diamonds  and  pearls. 
He  dresses  fantastically,  makes  grimaces,  is  filthy  in  his 
habits,  for  he  gobbles  his  food  with  his  hands,  and  also 
smears  his  clothes  with  it.  He  is  sleepless,  and  does  not 
take  his  food  well,  or  chew  it  like  a  rational  mortal.'  The 
attacks  subside  in  about  six  weeks,  and  then  he  is  found  to 
be  a  sensible,  useful,  agreeable  fellow. 

VI.  Hallucinations,  Homicidal  Impulse,  Extreme  Agitation  and 

Tremor,  Gastric  Symptoms. 

C.  a  married  woman,  set.  34.  '  Hears  imaginary  voices 
which  abuse  her.     She  tried  to  jump  out  of  the  window  in 


304  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

order  to  throttle  people  who  she  believed  were  calling  her 
names  in  the  street  (hallucinations  of  hearing).  Says  she 
saw  God  and  the  angels  in  heaven.  She  is  in  an  extreme 
state  of  violent  agitation  with  general  tremor,  and  her  eyes 
look  wild ;  tongue  tremulous  ;  left  pupil  larger  than  right.' 
The  excitement  was  followed  by  depression  of  mind,  and 
gastric  irritation  with  sickness  and  inclination  to  vomit  after 
food.  She  is  then  described  as  '  still  shaky  and  tremulous, 
and  feeling  very  nervous.  The  memory  is  good,  though 
impaired  as  to  some  of  the  most  recent  events  of  her  excite- 
ment. Remembers  being  taken  to  the  police  office,  where 
she  saw  the  heavens  and  the  Judgment.  Complains  of 
palpitation.  Tendon  reflex  impaired  ;  plantar  reflex  sluggish.' 
Recovered. 

VII.  Acute  Mania  of  Wild,  Reckless,  Abusive  Type. 

D.,  another  married  woman,  aet.  40,  was  a  reckless,  fiendish 
woman,  who  sulked  and  stormed  by  turns.  Mental  con- 
fusion and  irritability  like  that  of  the  post-epileptic  state 
were  manifested.  Asked,  '  Where  are  you  going  to  ?'  when 
she  moved  suddenly  from  her  chair,  she  answered,  '  To 
hell,  if  you  know  where  that  is.'  Tongue  furred  and  very 
tremulous.  Pupils  rather  contracted,  but  active ;  hands 
tremulous  ;  pulse  120 ;  fixed,  glassy  stare.  Later,  when 
the  toxic  effects  began  to  wear  off,  she  complained  of 
frontal  headache,  and  desquamation  of  the  hands  occurred. 
The  left  pupil  was  larger  than  the  right,  and  she  had 
hallucinations  of  hearing,  which  may  have  persisted  all 
the  time.  Imagined  she  heard  people  say,  '  She  steals.' 
Still  later  she  complained  of  attacks  of  giddiness,  and  the 
tongue  remained  foul.  Soon  after,  the  tongue  cleared  up, 
the  hallucinations  ceased,  normal  consciousness  was  restored, 
she  made  herself  useful,  and  was  discharged  recovered. 

It  should  he  noted  here  that  hallucinations  of  hearing  and 
delusions  of  conspiracy  and  persecution  are  often  recovered  from 
in  acute  alcoholic  insanity,  even  when  the  patient  has  been  insane 
several  times. 


ALCOHOLIC  INSANITY— CLINICAL  ILLUSTRATIONS     305 


Examples  of  Dipsomania. 

The  following  is  a  type  familiar  to  all  practitioners,  and  is 
taken  from  records  of  private  practice.  A  brief  sketch  of  the 
man's  life-history  is  given. 

VIII.  R.  B.,  male,  set.  50,  son  of  a  publican,  and  brought 
up  at  a  public-house  until  adult  life.  No  occupation.  Took 
to  drink  early  in  life,  when  he  would  at  intervals  get  drunk. 
His  father  died,  and  left  him  a  fair  amount  of  cash,  which 
he  soon  got  rid  of  by  drinking.  At  middle  age  he  had 
become  a  confirmed  drunkard,  only  rarely  for  a  week  or 
fortnight  being  sober.  He  had  money  left  him  several  times 
by  relatives,  which  he  succeeded  in  getting  through  by  means 
of  drink  with  marvellous  rapidity.  For  the  last  ten  or  more 
years  of  his  life  his  gait  was  tottery,  his  hands  were  shaky, 
his  eyes  staring  and  vacant,  and  frequently  bloodshot. 
The  quantity  of  solid  food  which  he  could  take  gradually 
diminished,  and  for  the  last  two  years  or  more  he  lived 
without  solid  food,  only  taking  spirits  and  milk,  or  some 
fluid  preparations  of  meat,  as  beef-tea  or  chicken  soup.  He 
was  not  particular  (at  least  during  the  last  few  years)  what 
spirit  he  took,  but  would  frequently  ring  the  changes  in  a 
single  day  on  rum,  whisky,  gin,  and  brandy.  As  time 
went  on,  his  kidneys  became  affected,  afterwards  his  heart 
and  liver,  and  before  his  death  his  legs  and  abdomen  were 
immensely  oedematous  and  ascitic  ;  his  face  was  puffy  and 
bloated  ;  his  skin  jaundiced  ;  his  eyes  bloodshot ;  his  breath- 
ing difficult  and  embarrassed  ;  his  sight  indistinct  ;  he  was  the 
subject  of  illusions  and  hallucinations  of  sight  and  hearing, 
and  had  delusions  of  suspicion  of  those  around  him.  He 
was  constantly  calling  out  for  drink  (he  had  lived  in  a 
public-house  again  for  several  years  before  his  death).  He 
suffered  from  albuminuria,  and  occasionally  from  hsematuria, 
and  eventually  died  of  ursemic  coma.  There  seems  in  this 
case  to  have  been  a  distinct  hereditary  tendency,  and  there 
were  occasional  pauses  in  his  drinking  habits,  the  craving 
coming  on  in  fresh  accessions  time  after  time,  till  at  last  the 
drinking  became  continuous. 

20 


3o6  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

Cases  of  dipsomania  occur  which  come  under  asylum  care 
either  as  voluntary  boarders  or  as  legal  committals.     - 

IX.  J.  B.  was  a  medical  man  in  the  Indian  service,  and 
he  took  first  to  opium  and  afterwards  to  alcohol,  but  the 
starting-point  was  an  injury  to  his  elbow-joint  with  excru- 
ciating neuralgia.  When  the  arm  recovered,  his  general 
health  was  so  shattered,  and  his  nerve  so  far  gone,  that  a 
fierce,  uncontrollable  craving  for  alcohol  was  induced,  and 
after  many  crises  of  the  drink- craving,  coupled  with  the 
appetite  for  opium  which  still  continued,  and  many  attacks 
of  remorse  and  repentance,  he  placed  himself  voluntarily  in 
an  asylum,  where  his  regular  manner  of  living,  healthy 
surroundings,  and  freedom  from  temptation  worked  apparent 
wonders.  His  self-control  could  be  tested  by  inviting  him 
to  supper  in  the  medical  officers'  room,  where  everyone  had 
drink  but  himself.  It  did  not  turn  a  hair  of  him.  After 
more  than  a  year  of  this,  he  was  suddenly  sent  for  because 
of  family  trouble  at  home,  and  even  that,  for  a  time  at  least, 
was  insufficient  to  upset  him  ;  but  the  wear  and  tear  of 
anxiety  and  trouble  eventually  told  on  him,  the  strain  was 
too  much,  and  he  broke  away  from  restraint  entirely. 

X.  Notes  of  a  Case  of  Chronic  Alcoholic  Insanity  admitted  Ten 
Year's  ago ;  a  Miner ;  Delusions  of  Suspicion  and  Unseen 
Agency ;  Hallucinations  of  Hearing. 

M.  C,  set.  33.  '  This  man  was  for  years  a  chronic  soaker, 
but  always  fit  for  work  until  lately,  when  he  showed  incipient 
signs  of  insanity,  at  first  merely  morbid  suspicion  and  the 
hearing  of  peculiar  sounds.  Now  he  is  unmistakably  insane, 
and  his  hallucinations  and  perverted  sensations  are  most 
troublesome.  He  has  hallucinations  of  hearing  and  sight. 
He  hears  the  Almighty  "  and  obeys  orders."  Takes  fits  of 
partial  stupor,  with  eyes  suffused,  slight  jaundiced  appear- 
ance of  skin,  and  angry  expression.  In  this  state  of 
stupidity  he  is  sullen,  suspicious,  refuses  food,  the  head  is 
hot,  the  pupils  small  and  insensitive.' 

Notes  Two  Years  after. — '  M.  C.  is  most  dangerous;  has 
made  an  attempt  on  the  life  of  reporter  twice,  once  with  a 


ALCOHOLIC  INSANITY— CLINICAL  ILLUSTRATIONS    307 

spade.  These  attempts  are  true  homicidal  attempts,  and  are 
preceded  by  a  distinct  aura  in  the  breast,  working  upwards. 
Delusions  entertained  that  doctor  only  discharges  Catholics, 
that  men  are  in  women's  clothes  in  the  female  wards.' 

Present  State, — Much  less  frank,  more  reserved,  sullen,  and 
unsociable.  Has  now  believed  for  some  years  that  a  battery 
in  the  doctor's  house  is  connected  with  his  frame,  and  dis- 
charges electricity  into  him.  He  has  been  indifferent  to  his 
wife,  but  not  to  his  children.  Indeed,  there  seemed  from 
his  expression  to  be  a  positive  aversion  to  his  wife,  and  it  is 
quite  consistent  with  this  form  of  insanity  that  he  should 
entertain  delusions  reflecting  on  her  character. 

Alcoholic  Dementia. 

XI.  Case  of  a  Chronic  Soaker  with  Paretic  Symptoms  and  Signs 
of  Mental  Decay. 

N.  M.  T.,  aet.  57,  has  been  a  chronic  drinker  for  many  years. 
His  appearance  suggests  it.  He  is  fairly  well  preserved.  He 
shuffles  with  his  feet  in  walking,  looks  at  anyone  with  an 
expressionless  stare,  speaks  hesitatingly  and  thickly,  and  is 
slow  in  his  mental  time-reaction.  His  memory  for  recent 
events  is  much  impaired.  When  being  tested  he  is  roused 
up,  and  is  evidently  conscious  of  his  impaired  memory,  for 
he  lights  shy  of  direct  answers  to  questions,  being  afraid  to 
commit  himself.  At  times  he  is  restless,  wandering  about 
in  a  half-dazed  condition,  and  then  when  questioned  he  is 
found  to  be  more  than  usually  stupid  and  confused.  Some- 
times he  has  childish  outbursts  of  crying,  and  cannot  give 
any  explanation  ;  they  seem  to  be  mere  emotional  outbursts. 

The  motor  symptoms  have  been  slight,  and  there  is  nothing 
beyond  slow  shuffling  locomotion,  feeble  grip,  and  thickness 
of  speech  ;  but  it  is  observed  that  the  sense  of  touch,  impaired 
a  year  ago  when  he  was  admitted,  is  now  more  seriously 
involved.  Sense  of  smell  much  impaired.  Knee  reflexes 
impaired,  especially  left.     Dynamometer,  R.  40,  L.  40. 

For  a  time  it  seemed  likely  that  this  case  would  improve 
under  favourable  hygienic  conditions,  and  forced  abstention 
from  alcohol,  but  the  improvement  was  merely  temporary. 

20 — 2 


3o8  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

XII.  Insanity  from  Opium  Indulgence. 

Mrs.  M.,  get.  45.  The  medical  certificates  in  this  case 
stated  that  she  was  known  to  be  addicted  to  opium-drinking 
for  years,  that  she  was  under  the  delusion  that  people  came 
into  her  room  at  night,  even  though  the  door  was  locked, 
that  they  stole  things  and  tumbled  everything  upside  down. 
She  had  hallucinations  of  hearing,  but  not  of  sight.  She> 
charged  her  neighbours  by  name  with  stealing  and  objec- 
tionable practices,  and  she  attacked  them  and  threatened  to 
'  rip '  them  up.  Later  she  was  described  as  having  halluci- 
nations of  sight. 

Her  state  on  admission  to  the  asylum  is  thus  described  : 

Circulatory . — Pulse  78,  small  and  compressible.  Second 
sound  of  heart  prolonged. 

Respiratory. — Normal. 

Digestive. — Tongue  moist,  flabby,  fairly  clean ;  abdomen 
full  and  tympanitic  in  some  parts,  dull  to  percussion  on  right 
side,  especially  over  transverse  colon  ;  flatulence,  anorexia. 

Nervous. — Eyes  brown,  pupils  medium  active  ;  no  motor 
or  sensory  impairment ;   no  tremor. 

Mental. — She  is  quiet  and  composed,  reticent  to  a  fault, 
quite  at  home  in  the  asylum.  She  evinces  no  interest  in  her 
husband  (her  children  are  dead),  and  has  no  moral  sense 
whatever.  She  speaks  of  her  husband  as  if  he  were  in  no 
way  related  to  her. 

History. — It  is  interesting  to  note  the  history  of  her  opium 
habit  as  given  by  her  husband.  It  was  first  given  medicinally 
for  insomnia  seventeen  years  ago,  after  a  confinement,  but 
only  for  a  few  days.  She  afterwards  took  to  it  herself,  and 
the  dose  mounted  up  till  she  took  about  2  ounces  daily. 
The  craving  for  it  was  strongest  in  the  evening.  She  drank 
whisky  as  well.  Has  had  a  family  of  five  and  two  mis- 
carriages. 

Syphilitic  Insanity. 

XIII.  Syphilis  and  Alcoholic  Excess. 

M.  B.,  prostitute,  set.  20.  Two  recent  cicatrices  on  vulva; 
several  condylomata ;  syphilitic  infection  three  months  ago  ; 
hair  falling  out.      Has  been  drinking. 


SYPHILITIC  INSANITY— CLINICAL  ILLUSTRATIONS     309 

Mental  State. — '  She  imagines  she  is  followed  by  men  and 
women  who  have  designs  on  her  life.  She  has  hallucina- 
tions— hears  their  voices  and  answers  back.  She  has  a 
sensation  of  something  she  cannot  explain  running  up  her 
back.  She  occasionally  starts  up  and  looks  round  the  room 
for  someone.' 

Following  this  came  an  intermediate  state  before  recovery, 
with  sensory  perversions  dissipated,  extreme  mental  depres- 
sion, and  painful  retrospection.  After  three  months  she  was 
discharged  recovered.  Here  there  were  undotthtedly  in  active 
operation  two  poisons — syphilitic  and  alcoholic. 

XIV.  Illegitimacy,  Disowned,  Prostitute,  Insane. 
C.  L.  is  now  a  woman  of  forty-five,  and  has  been  insane 
for  ten  years.  As  in  almost  all  syphilitic  cases,  there  is  a 
history  here  of  alcoholic  indulgence.  She  was  sent  to  prison  ; 
while  there  became  deaf,  and  developed  hallucinations  of 
hearing,  viz.,  that  witches  speak  to  her,  and  are  the  cause 
of  her  being  so  deaf.  She  has  had  this  hallucination  con- 
sistently for  ten  years.  •  She  is  rather  light-minded  and 
frivolous,  has  little  moral  sense,  has  numerous  hypochon- 
driacal ideas  which  may  be  founded  on  obscure  pains  which 
she  feels  in  her  bones  and  elsewhere.  She  is  in  apparently 
robust  health,  but  her  head  is  very  bald. 

XV.  Gonorrhoea,  Syphilis,  Delusions  of  Persecution,  Megalo- 
mania. 
J.  M.  B.,  set.  27.  A  very  complete  history  of  primary  and 
secondary  effects.  .  Hallucinations — hears  people  whispering 
to  him  at  night.  Says  the  sounds  come  through  a  phono- 
graph into  his  system,  and  through  the  pores  of  his  body. 
They  do  it  to  annoy  him,  and  a  young  woman  is  at  the 
bottom  of  it.  Imagines  that  the  general  public  speak  about 
him  in  order  to  torment  him,  and  accuse  him  of  importing  a 
bad  smell.  At  the  same  time  he  entertains  the  delusion  that 
he  is  to  get  three  millions.  This  case  is  evidently  a  near 
approach  to  the  degenerate  type.  Poor  physique,  narrow 
chest,  weak  expression.  He  suffers  from  periodical  attacks 
of  headache  in  vertex  ;  is  hypochondriacal,  restless,  unsettled, 
amorous.     Has  not  recovered. 


3IO  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

XVI.  Alcoholic  Excess,  Syphilis,  Sunstroke;  Old  Soldier. 

J.  A.,  ast.  58.  Suffered  from  attacks  of  dizziness  and  deaf- 
ness ;  then  followed  delusions  of  persecution,  irritability, 
violence,  facile  disposition,  thickness  of  speech,  and  slight 
ptosis  of  the  left  eyelid.  This  man  improved  very  much, 
and  was  discharged, 

XVII.  Syphilis  in  South  Africa  Eleven  Years  ago  ;  Hemiplegia, 

Insanity. 

A.  P.,  «t.  36,  married.  Seven  years  ago  lost  power  in 
left  side,  and  speech  failed.  Recovered  these,  but  a  year 
later  left  hemiplegia  reappeared,  and  he  was  unable  to  work. 
On  admission  to  the  asylum,  he  was  found  to  have  left 
hemiplegia  with  inability  to  balance  himself  properly  on 
either  leg,  or  to  walk  along  a  straight  line.  His  speech  was 
drawling  and  thick,  the  pupils  sometimes  unequal,  but  quite 
responsive  to  light  and  accommodation.  He  is  indolent, 
lethargic,  mentally  weak  and  inactive  ;  his  memory  is  some- 
what impaired.  He  is  childish,  petulant,  and  takes  no 
interest  in  his  wife,  who  has  been  left  to  her  own  resources, 
or  in  his  child.  He  is  suspicious  of  his  wife,  and  refuses  to 
write  to  her,  because  he  believes  there  is  underhand  work 
carried  on  between  her  and  the  asylum  doctors.  Before  he 
was  taken  to  the  asylum,  his  attack  of  paralysis  so  depressed 
him  that  he  made  a  feeble  attempt  at  suicide  by  drowning, 
but  had  not  courage  to  finish  what  he  had  begun. 


CHAPTER  XV. 

INSANITY  OF  PREGNANCY— PUERPERAL  INSANITY- 
INSANITY  OF  LACTATION. 

The  question  of  the  pathognomonic  significance  of  mental  symptoms  at 
these  periods  as  evidences  of  distinct  forms  of  insanity — Insanity  of 
pregnancy  rare  —  The  melancholic  form  predominates  —  Moral 
perversion  a  frequent  symptom — Causes — Treatment — Puerperal  in- 
sanity— Ages  most  liable — Primipara  or  multipara — Date  of  attack 
— Previous  history — Heredity— Health  during  pregnancy — Nature 
of  labour  and  sequelae  —  Premonitory  signs  or  danger-signals — 
Symptoms  of  mania — Melancholia— Stupor — Physical  conditions — 
Prognosis — Treatment. 

These  three  mental  episodes  of  what  are  otherwise  physio- 
logical conditions,  viz.,  pregnancy,  the  puerperal  state  and 
lactation,  have  long  been  recognised  by  the  names  given  at 
the  head  of  this  chapter.  Some  authorities  have  found  it 
impossible  to  conceive  from  experience  or  otherwise  of  any 
necessity  for  recognising  the  existence  of  these  forms.  They 
have  been  unable  to  discover  anything  pathognomonic  or 
uniform  and  distinctive  in  the  symptoms  or  course  of  mental 
disease  arising  at  any  of  the  periods  mentioned.  If  this 
objection  is  strained  to  its  logical  conclusion,  we  should  not 
be  able  to  give  a  classification  of  insanity  at  all. 

Two  arguments  against  it  are  these :  (i)  that  we  have  to 
deal  with  patients  who  have  passed  or  are  passing  through 
a  physiological  crisis,  a  critical  period  of  female  life,  a  period 
attended  with  more  or  less  nervous  tension  and  mental 
anxiety,  and  this  period  of  great  physical  changes  is  clearly 
correlated  to  these  nervous  and  mental  symptoms ;  (2)  the 
condition  of  pregnancy,  the  puerperal  state  and  lactation, 
though  presenting  in  some  respects  mental  peculiarities  which 
might  be  associated  with  any  other  period,  yet  present  also 
many  features  which  are  so  frequently  repeated  in  the  puer- 


312  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

peral  and  allied  insanities,  and  which  give  many  cases  so 
strong  a  family  resemblance,  that  it  would  be  unreasonable 
to  group  them  under  any  other  name. 

Some  symptoms  may  almost  with  certaint}^  be  referred  to 
one  particular  stage  of  this  crisis  in  female  history,  but  other 
symptoms  may  be  referred  to  all.  If  we  should  endeavour 
to  classify  the  symptoms  of  bodily  disease,  taking  these 
symptoms  alone  just  as  we  might  take  mental  symptoms 
alone,  without  reference  to  the  physical  conditions  under- 
lying them,  we  should  find  confusion  arising,  for  we  are  not 
able  thus  to  put  on  one  side  heart  disease,  on  the  other  side 
lung  disease,  or  it  may  be  kidney  disease.  An  all-around 
examination  and  diagnosis  of  the  case  enables  us  to  segregate 
it  from  others  with  perhaps  similar  mental  symptoms,  but  a 
different  history,  physical  state,  and  causation.  Indigestion 
may  be  taken  for  heart  disease,  until  we  apply  the  stethoscope. 
It  may  be  argued  that  heart  disease  causes  definite  symptoms, 
and  the  puerperal  state  does  not ;  but  this  is  not  quite  correct ; 
besides,  the  mental  disease  is  only  potential,  and  often  remotely 
so,  without  the  pregnant  or  puerperal  state.  In  all  cases  we 
endeavour  to  discover  a  particular  physical  state  in  relation 
to  or  in  explanation  of  symptoms,  and  we  take  the  physical 
state  and  the  symptoms,  whether  they  be  cardiac,  respiratory, 
renal  or  mental,  as  the  tout  ensemble  of  the  disease. 

We  are  bound,  of  course,  to  admit  that  the  mental  phase 
is  secondary  to,  and  necessarily  a  result  of,  the  puerperal 
state ;  but  there  is  more  than  mere  puerperal  causation  to 
take  into  account  in  many  cases,  and  the  accident  of  preg- 
nancy, the  puerperal  state  or  lactation  may  be  only  the  final 
cause.  While  it  is  true  that  some  cases  become  insane  apart 
from  these  periods,  it  is  quite  correct  to  say  that  the  great 
majority  now  become  insane  for  the  first  time,  and  in  their 
mental  symptoms  have  a  family  resemblance  to  each  other. 
Moreover,  it  avails  little  to  say  that  previous  to  this  attack 
of  puerperal  insanity  the  patient  was  insane  before  marriage, 
or  has  passed  through  puerperal  crises  on  previous  occasions 
without  mental  disturbance.  As  has  been  fully  explained  in 
the  chapter  on  causation,  the  resistance  of  the  individual 
must    be    taken    in    conjunction    with    causes,    in    order    to 


INSANITY  OF  PREGNANCY 


appreciate  the  sum  total  of  the  aetiology  of  an  attack,  and 
it  would  obviously  be  absurd  to  say  that  diminished  resistance 
at  the  particular  period  would  produce  insanity  without  the 
period  itself  to  precipitate  it. 

Insanity  of  Pregnancy. 

We  are  still  far  from  possessing  an  adequate  conception 
of  the  psychology  of  pregnancy.  It  is  a  curious  fact  that, 
while  no  time  of  a  woman's  life  is  attended  so  frequently 
with  nervous  and  mental  changes  short  of  insanity,  women 
who  are  pregnant  rarely  become  insane.  So  extremely  rare 
is  this  form  of  insanity  that  Clouston  had  experience  of  only 
fifteen  cases  in  nine  years  in  an  asylum  which  admits  nearly 
170  female  patients  a  year.  Dr.  Batty  Tuke,  in  the  Edinburgh 
Medical  Journal,  1865-66,  records  the  observations  made  on 
twenty-eight  cases  taken  from  the  records  of  the  same  asylum 
extending  over  a  considerable  number  of  years.  Other 
authorities  have  had  a  similar  experience  of  the  extreme 
rarity  of  this  form  of  mental  disease.  In  twelve  years  I  had 
twelve  cases,  of  which  two  were  merely  incidents  of  recurrent 
insanity,  and  under  treatment  during  these  twelve  years  were 
638  recent  cases  of  female  insanity.  My  experience,  there- 
fore, gives  a  larger  percentage  than  Clouston's.  From  these 
limited  results,  it  is  not  surprising  that  somewhat  different 
accounts  should  be  given  in  various  text-books ;  but  a  careful 
study  and  comparison  of  the  whole  allows  of  certain  general 
conclusions. 

It  is  clear  at  least  that,  whatever  forms  of  insanity  may 
appear  at  this  time,  the  melancholic  form  predominates. 
The  experience  of  Savage  is  that  melanchohc  insanity 
with  hypochondriacal  symptoms  is  the  most  general  form. 
Clouston,  on  the  other  hand,  had  nine  cases  maniacal,  and 
six  melancholic.  Regis  states  that  the  insanity  of  pregnancy 
habitually  takes  the  melancholic  form.  Batty  Tuke  found 
fifteen  cases  of  melancholia,  five  of  dementia  (stupor)  with 
melancholia,  four  of  dipsomania,  two  of  moral  perversion,  and 
two  of  mania  with  exaltation.  My  experience  has  been  that 
five  out  of  ten  were  maniacal  and  five  melancholic  ;  but  to  this 


314  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

must  be  added  the  fact  that  the  maniacal  cases  sometimes 
exhibit  a  distinct  moral  perversion,  a  surly,  unsociable, 
irritable  disposition,  which  gives  the  disease  a  characteristic 
feature  of  its  own,  and  some  of  these  cases  might  be  called 
surly  melancholies  rather  than  maniacs. 

Before  going  into  details,  it  may  be  well  to  keep  in  view 
the  fact  that  the  nervous  and  mental  symptoms  of  pregnancy 
often  approach  very  nearly  to  the  borderland  of  insanity. 
While  a  great  deal  is  conceded  to  the  pregnant  woman,  and 
every  reasonable  excuse  that  can  be  offered  for  her  change 
of  character,  her  peculiar  longings,  and  her  trying  disposition, 
is  made,  it  must  be  admitted  that  moral  perversion  as  a 
feature  of  this  condition  raises  serious  questions  of  mental 
unsoundness  and  irresponsibility.  Untruthfulness  is  some- 
times a  symptom  of  what  would  be  called  normal  pregnancy  ; 
stealing,  or,  to  use  a  more  correct  term,  kleptomania,  is  a 
symptom  which  often  leads  pregnant  women  into  the  grip  of 
the  law.  This,  observed  many  years  ago  by  Laycock,  is  also 
mentioned  by  Regis  and  Clouston,  and  Dr.  J.  F.  Sutherland 
informs  me  that  while  surgeon  of  H.M.  Prison,  Glasgow, 
he  had  frequently  to  examine  cases  of  pregnancy  imprisoned 
for  stealing.  Bearing  these  facts  in  mind,  it  will  not  surprise 
us  to  find  that  the  moral  sense  is  in  many  cases  affected. 

The  most  potent  causes  of  insanity  of  pregnancy  are 
illegitimacy  and  wife  -  desertion.  Three  out  of  ten  of  my 
cases  were  cases  of  desertion  ;  four  were  cases  of  illegitimacy. 
This  fact  is  confirmed  by  the  experience  of  others. 

Moral  causes  operate  seriously.  One  woman,  recently 
married,  had  run  into  debt  and  deceived  her  husband  in 
other  ways  ;  remorse  seized  her,  or  perhaps  it  was  fear  of 
being  found  out.  In  the  melancholic  form  there  may  be 
simply  depression,  a  weariness  of  life  without  impulse  to 
destroy  it,  or  it  may  be  an  acute  anxiety  as  to  the  future. 
In  my  experience  there  was  only  one  determined  suicidal 
impulse,  whereas  Clouston  records  seven  out  of  fifteen,  some 
of  them  being  desperately  suicidal.  It  must  be  added,  how- 
ever, that  in  one  case  under  treatment  in  my  wards,  on  the 
approach  of  labour,  violence  to  the  abdomen  was  attempted 
in  the  hope  of  killing  the  child.     This  woman — married  and 


INSANITY  OF  PREGNANCY  315 

deserted- — might  be  regarded  as  a  subject  of  melancholia  and 
moral  insanity  combined,  for  her  moral  sense  was  decidedly 
blunted. 

One  important  fact  ought  not  to  be  overlooked,  viz.,  that 
the  emotional  nature,  no  matter  what  the  general  complexion 
of  the  mental  symptoms  may  be,  is  often  perverted,  whether 
it  be  a  case  of  melancholia,  mania,  or  moral  insanity  ;  there 
is  frequently  sexual  aversion,  a  dislike  of  the  husband  which 
may  be  nameless  in  its  character,  purely  subjective  and  not 
impulsive,  or  lead  to  violent  outbreaks. 

The  maniacal  form  may  be  delirious  in  character  ;  it  may 
be  hysterical,  or  assume  the  character  of  acute  mania  with 
exaltation.  Two  of  my  cases  were  of  the  acute  delirious  type 
— one  with  epilepsy,  which  recovered,  and  one  with  typhoid 
fever,  which  died.  Where  it  appears  with  a  strong  moral 
perversion,  it  may  be,  as  already  suggested,  rather  a  per- 
verted melancholia  than  true  mania,  the  aggressive  outbreak, 
the  surly  exhibition  of  discontent,  the  outcome  of  an  unhappy, 
angry  state  of  mind.  Such  patients  are  obstinately  idle  and 
suspicious,  rude,  quarrelsome,  sour  and  unsociable,  much 
given  to  brooding,  and  so  taciturn  that  it  is  often  difficult 
to  get  at  their  thoughts. 

Insanity  of  pregnancy  may  come  on  in  any  month  of 
pregnancy,  and  while  it  generally  makes  its  appearance 
during  the  later  months,  it  may  be  found  as  early  as  the 
second,  or,  for  all  I  know  to  the  contrary,  earlier.  One  of 
my  cases  occurred  in  the  second  month,  an  exceedingly 
suicidal  one.  Batty  Tuke  records  three  in  the  third  month, 
five  in  the  fifth,  one  in  the  sixth,  nine  in  the  seventh,  one 
in  the  eighth,  and  nine  not  reported.  Some  are  agreed  that 
it  occurs  oftener  in  later  pregnancies,  while  others  say  that 
it  occurs  in  the  earlier,  and  is  most  frequent  in  primipara. 
Considering  that  it  often  occurs  in  cases  of  illegitimacy, 
the  susceptibility  of  the  primiparous  state  should  be  dis- 
counted, for  the  moral  cause  is  here  to  be  taken  most  into 
account.  I  think  it  extremely  likely  that,  as  Blandford 
observes,  it  is  most  usually  to  be  found  in  women  who  have 
had  many  children  rapidly,  and  who  become  pregnant 
in  an   exhausted  condition.      The    prognosis,  according  to 


3i6  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

Clouston,  is  fairly  good,  60  per  cent,  of  his  cases  having 
recovered.  My  experience  was  seven  recoveries  out  of  ten, 
two  cases  that  did  not  recover  being  both  cases  of  melan- 
choha ;  in  the  one  the  child  was  illegitimate,  the  other 
was  the  case  of  a  deserted  wife,  who  exhibited  great  moral 
perversion  ;  the  tenth  died.  It  is  usually  expected  that  with 
parturition  recovery  will  take  place,  but  very  often  this  is  not 
the  case.  Recover}^  in  one  of  my  patients  did  not  come  on 
for  eighteen  months,  and  several  did  not  recover  for  six 
months  after  parturition. 

The  treatment  in  such  cases  must  be  in  the  direction  of 
improving  the  general  health,  increasing  the  stability  of  the 
nervous  system,  promoting  quiet,  such  gentle  exercise  as  is 
desirable  in  the  open  air,  and  every  rational  means  of  pro- 
curing sleep. 

The  question  of  precipitating  labour  is  not  likely  to  arise, 
for  it  is  astonishing  how  tolerant  the  uterus  is  of  maniacal 
disturbance,  great  motor  excitement  and  prolonged  sleep- 
lessness. I  have  been  consulted,  however,  by  medical  men, 
who  have  been  alarmed  and  anxious  as  to  the  outcome  of 
such  cases,  as  to  the  propriety  of  inducing  labour.  The 
circumstances,  however,  did  not  appear  to  me  to  justify  this 
course,  and  the  patients  were  delivered  at  the  proper  time 
without  injur}'  to  mother  or  child. 

Attention  requires  to  be  given  to  the  state  of  digestion 
and  the  condition  of  the  bowels.  Much  relief  to  the  patient's 
mental  state  is  in  this  way  afforded,  and  a  quieter  mental 
period  ensues.  It  is  not  wise  to  thwart  these  women  as 
regards  predilections  for  particular  eatables  or  drinkables. 
A  certain  latitude,  which  might  be  thought  unreasonable,  is 
perfectly  safe ;  but  if  a  compromise  can  be  effected — and  it 
can  by  the  exercise  of  some  judgment  and  tact  in  many 
cases — then  a  great  deal  is  gained  in  the  physiological  diet- 
ing of  the  patient. 

In  the  mental  depression  and  anxiety,  with  vague  fears,  of 
primipara,  a  great  deal  can  be  done  by  cheerful  society, 
drives  in  the  open  air,  varied  interests  and  occupations  to 
tide  over  a  trying  time.  Such  patients  should  not  be  allowed 
to  brood  or   to    isolate  themselves   from   others  ;    for  their 


PUERPERAL  INSANITY  317 

thoughts  always  run  in  the  one  direction,  and  by  the  summa- 
tion of  morbid  stimuh  thus  produced,  they  overcloud  the 
mind,  and  make  life  sad  and  wearisome. 

Puerperal  Insanity, 

Puerperal  insanity  is  .much  more  frequent  than  the 
insanity  of  pregnancy,  and  there  must  be  many  minor  cases 
— and  the  same  to  a  less  degree  is  probably  true  of  the 
insanity  of  pregnancy — which  do  not  reach  asylums  for  very 
obvious  reasons.  As  far  as  they  can,  medical  men  and  the 
friends  of  the  patients  will  use  every  means  to  prevent  such 
cases  being  sent  to  asylums.  It  is  probable  that  in  the 
houses  of  the  better  classes,  where  ways  and  means  are 
ample,  many  cases  are  treated  by  private  practitioners ;  and 
one  reason  why  there  is  a  discrepancy  in  the  statistics  of 
different  asylums  is,  that  some  asylums  are  entirely  reserved 
for  patients  of  the  poorer  classes,  while  others  are  in  whole 
or  part  reserved  for  private  paying  patients.  About  5  per 
cent,  of  all  female  cases  admitted  from  the  lower  ranks  of  life 
suffer  from  puerperal  insanity.  It  must  be  self-evident  that, 
for  sentimental  and  other  reasons,  as  often  as  possible  patients 
suffering  from  this  disease  should  be  treated  at  home.  One 
cause  of  puerperal  insanity  is  emotional  disturbance  at  a 
time  when  self-control  must  be  below  par,  and  added  to 
this  the  great  physiological  demands  made  upon  the  system 
is  such,  that  there  comes  a  feverish  disorder  and  insanity 
by  sympathy.  This  frequently  implies  that  insanity  is 
potential  only  under  extraordinary  physical  conditions,  and 
where  not  acute,  or  where  the  symptoms  are  transient,  home 
treatment  is  sufficient.  Further,  the  stigma  of  lunacy  is 
considerably  minimized,  if  not  entirely  obliterated,  by  private 
treatment.  Having  made  a  very  careful  study  of  this  sub- 
ject for  many  years,  this  chapter  will  deal  largely  with  my 
own  experience.  Where,  however,  the  researches  of  others 
will  throw  further  light  on  the  subject,  reference  will  be 
made  to  them. 

Age  at  which  the  Attack  appears. — It  used  to  be  an  article 
of  faith  with  authorities  on  this  subject,  that  women  under 
thirty  would  not  readily  succumb  to  a  mental  attack,  while 


3i8  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

those  over  thirty  were,  conversely,  much  more  Hable  to  it. 
This  is  on  all-fours  with  the  doctrine  which  has  prevailed, 
and  still  is  entertained  by  some,  that  labour  is  much  more 
serious  after  thirty  than  before  it.  Whatever  individual 
opinions  may  still  obtain,  one  thing  is  certain,  that  puerperal 
insanity  is  by  no  means  exclusively  reserved  for  those  of 
later  life.  It  may  be  more  than  formerly,  for  the  ages  at 
which  women  marry  alter  with  the  times  in  which  they  live,  , 
and  it  is  certain  that  a  larger  number  now  marry  above 
thirty  than  formerly.  This  fact  alone  must  render  statistics 
on  the  subject  useless,  unless  we  obtain  satisfactory  marriage 
statistics  of  the  districts  from  which  our  puerperal  cases 
come.  Tuke's  results  certainly  contradict  some  prevalent 
views  on  the  subject,  for  he  found  forty-one  cases  out  of 
seventy-three  under  the  age  of  thirty.  Out  of  my  first 
twenty  cases,  sixteen  were  under  thirty  on  their  first  attack. 

Pfimipara  or  Multipara. — The  number  of  previous  preg- 
nancies has  also  been  stated,  in  order  to  ascertain  whether 
frequent  pregnancies  are  more  productive  of  puerperal  in- 
sanity than  infrequent.  Without  statistics  of  the  number 
of  pregnancies  in  the  population  from  which  our  patients 
are  drawn,  we  are  unable  to  furnish  any  precise  data,  but  it 
will  probably  be  found  that  the  balance  of  evidence  is  against 
the  primiparous,  and  in  favour  of  multiparous  cases.  In 
addition  must  be  taken  into  account  the  intervals  between 
pregnancies. 

Date  of  the  Attack. — Puerperal  insanity  in  the  great  pro- 
portion of  cases  makes  itself  manifest  before  the  end  of  the 
first  week,  at  least  50  per  cent,  of  the  cases  showing  signs  of 
mental  change  within  this  limit.  Wiglesworth  gives  less. 
Tuke  gives  50  per  cent.,  and  my  experience  is  65  per  cent. 
The  date  on  admission  to  the  asylum  is  often  given — or 
perhaps  a  day  earlier — as  the  date  of  the  onset  of  the  attack  ; 
but  the  actual  beginnings,  if  a  careful  investigation  is  made, 
will  be  found  to  start  sooner.  In  some  they  may  start  the 
very  first  day.  The  fourth  and  the  fifth  days  are  critical 
days  in  my  experience  ;  but  any  time  during  the  first  week 
this  catastrophe  is  possible,  because  a  summation  of  stimuli, 
not  starting  merely  from  parturition,  but  coming  on  through 


PUERPERAL  INSANITY  319 

the  later  months  of  pregnancy,  accentuates  the  nervous 
tension  at  this  time  to  an  almost  uncontrollable  extent  in 
susceptible  subjects. 

Previous  History. — As  has  been  already  observed,  there  is 
a  natural  tendency,  especially  in  the  neurotic  and  mentally 
excitable,  to  nervous  and  mental  disorders  during  pregnancy. 
These,  though  mild  and  rarely  finding  expression  in  actual 
insanity  of  pregnancy,  may  seriously  affect  the  mental  prog- 
nosis when  labour  is  imminent.  I  found  that  mental  causes 
were  insidiously  at  work  for  weeks  or  months  of  pregnancy 
in  many  of  my  puerperal  cases.  A  morbid  habit  is  created, 
a  disposition  to  brood  over  and  magnify  the  anxieties,  dis- 
appointments and  bereavements  of  the  past,  or  to  foster  the 
religious  emotions  up  to  a  state  of  morbid  exaltation.  When 
a  mother  had  lost  a  child,  the  subject  was  sure  to  engross 
her  thoughts,  to  prey  upon  her  mind  with  the  intensity  of 
disease,  and  to  colour  her  delusions  afterwards.  I  was  struck 
with  the  remarkable  frequency  of  such  bereavements  in  the 
history  of  my  puerperal  cases,  and  it  seemed  as  if  the  state 
of  mind  in  a  woman  again  pregnant  just  after  losing  a  child 
might  be  expressed  in  the  words  Cm  bono  ?  The  other  causes 
of  mental  disturbance  not  amounting  to  insanity  during 
pregnancy  were  :  (i)  Desertion  by  husband,  (2)  poverty, 
(3)  illegitimacy,  (4)  fright,  (5)  dread  of  confinement,  (6)  various 
disorders  of  health  during  pregnancy,  (7)  insufficient  pause,  or 
none,  after  lactation,  and  frequent  pregnancies,  (8)  frequently 
recurring  miscarriages. 

Heredity. — Nervous  and  mental  susceptibility  is  found  to 
be  a  hereditary  acquisition  in  a  larger  number  of  cases  than 
might  have  been  supposed.  Wiglesworth  gives  it  at  25*8  per 
cent.,  and  Tuke  at  30  per  cent.,  and,  taking  cases  of  collateral 
heredity,  I  find  it  40  per  cent.  This  percentage  of  mine  does 
not  include  a  hereditary  history  of  intemperance  in  one  or 
more  parents. 

Health  during  Pregnancy.- — Decided  mental  depression 
will  be  found  in  a  considerable  number  of  cases,  sometimes 
hysteria,  and  not  infrequently  hypochondria.  There  is  often 
a  history  of  bodily  disease,  such  as  phthisis,  morbus  cordis, 
anaemia,  dyspepsia,  impairments  of  general  health,  etc.     In 


320  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

some  cases,  owing  to  very  straitened  circumstances  and 
poverty,  there  is  starvation  of  a  system  on  which  there  is 
great  demand  :  and  women  may  therefore  succumb  easily  to 
puerperal  insanity. 

Nature  of  Labotir,  and  its  Sequelce. — The  question  of  the 
influence  of  labour  itself  as  an  exciting  cause  has  received 
probably  more  attention  than  it  deserves.  In  Tuke's  cases 
instrumental  labour  is  credited  with  nine,  but  at  the  time 
when  his  paper  was  written  instrumental  labour  was  regarded 
as  a  much  more  serious  interference  with  the  course  of  events 
than  it  is  now.  The  same  may  be  said  of  chloroform  admi- 
nistration. In  my  experience  labour  was  not  irregular  or 
unduly  tedious  in  a  very  large  majority  of  the  cases,  but  it 
must  be  added  that  a  few  of  them  had  passed  through  severe 
operative  ordeals.  I  do  not  wish  to  discount  the  importance 
of  carefully  safe-guarding  patients  who  have  passed  through 
a  very  trying  period  at  the  time  of  labour,  but  desire  merely 
to  minimize  the  belief  that  trying  labours  are  frequent  elements 
in  the  causation.  The  whole  puerperal  period  is  one  of  more 
or  less  suppressed  excitement,  both  physical  and  mental. 
There  are  many  incidental  anxieties,  all  the  greater  that  the 
patient  is  often  in  a  high-strung,  nervous,  sensitive,  and 
susceptible  state.  Excitement  may  be  induced  by  apparently 
innocent  observations  on  the  part  of  the  doctor  or  nurse, 
because  the  patient  is  unable  to  cease  worrying  about  trifles 
if  she  is  of  a  nervous  disposition.  Trouble  with  the  milk- 
supply,  with  the  nipples,  with  the  crying  of  the  child,  thought 
on  family  cares  or  household  difficulties,  upset  the  equilibrium 
much  more  easily  than  at  ordinary  times.  Without  enlarging 
further,  it  is  enough  to  say  that  an  unstable  mental  balance 
can  be  rendered  more  unstable  by  the  slightest  sensory  dis- 
turbance. 

By  reason  of  their  close  anatomical  relation  with  the 
higher  brain  centres,  and  their  almost  psychic  functions,  it 
will  easily  a  priori  be  expected  that  the  special  senses  may 
have  much  to  answer  for  in  the  production  of  puerperal 
insanity.  Their  functions  are  inseparably  associated  with 
the  mind,  and  the  whole  well-being  of  the  organism  depends 
so    much   upon    the    impressions   which    they  receive    that 


PUERPERAL  INSANITY  321 

their  share  in  the  causation  should  be  clearly  recognised. 
The  ear  takes  in  bad  tidings,  and  at  this  critical  period 
conducts  noises  intensely ;  the  eye  is  open  to  distressing 
sights  and  exciting  literature,  and  the  functions  of  taste  and 
smell  are  apt  to  be  disordered.  The  nerve  centres  of  special 
sense  are  hyper-sesthesic.  The  most  usual  excitements  of 
this  class  are  those  affecting  sight  and  hearing.  One  lady's 
temperature  rose,  and  she  became  excited  for  twenty-four 
hours  without  inflammation,  as  a  result  of  reading  an  exciting 
novel ;  and  another  puerperal  patient,  hearing  outside  the 
voice  of  a  most  unwelcome  visitor,  was  similarly  affected. 
One  patient  was  upset  by  hearing  '  a  neighbours'  row '  on 
the  stair,  another  by  a  quarrel  between  the  husband  and  his 
mother-in-law.  The  perverted  state  of  the  nasal  and  oral 
secretions  is  apt  to  give  rise  to  a  bad  smell  and  taste,  which 
can  readily  be  misinterpreted  in  the  querulous  and  irritable 
state  of  the  patient. 

There  is  no  doubt,  whether  due  to  cerebral  anaemia  or  a 
toxsemic  condition,  the  special  senses  quickly  respond  to  the 
morbid  condition  of  things,  and  the  senses  become  extremely 
acute,  so  that  hallucinations  and  illusions  readily  occur. 

Many  of  the  unfavourable  sequelae  of  labour  are  due  to  the 
unfortunate  necessity  for  many  poor  women  being  out  of 
bed  on  the  third  or  fourth  day,  attending  to  their  household, 
their  husband  and  children.  It  is  not  surprising,  therefore, 
that  personal  neglect  should  be  the  consequence,  that  the 
uterus  should  become  the  seat  of  disease,  that  chills  and 
fevers  are  likely  to  attack  the  patient,  and  that  when  a  week 
is  over,  if  not  sooner,  a  wretched  state  of  the  general  health 
is  the  result,  and  the  mental  condition  suffers  accordingly. 
Yet  many  such  women  drag  along  their  existence  on  the 
verge  of  insanity  for  weeks  or  months,  and  it  is  -surprising 
how  seldom  they  are  so  seriously  affected  as  to  require  asylum 
treatment. 

Premonitory  Signs  or  Danger-signals. — A  most  important 
consideration  is  to  understand  what  symptoms  may  be 
regarded  as  danger-signals  in  the  puerperal  state.  In  the 
first  place  we  must  learn  all  that  can  be  known  of  the 
personal  and  family  history  of  the  patient,  of  her  normal, 

21 


322  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

mental,  and  nervous  character,  and  of  the  manner  in  which 
she  has  come  through  the  pregnant  state.  There  may  occur 
during  the  end  of  labour  a  momentary  excitement  which  is 
known  as  mania  transitoria,  usually  appearing  in  the  third 
stage  of  labour.  This  is  an  acute  state  of  temporary  frenzy, 
and  passes  off  with  the  birth  of  the  child ;  but  when  it  does 
occur,  although  temporary,  it  must  none  the  less  be  regarded 
as  a  danger-signal.  Transitory  attacks,  with  violent  if  not 
homicidal  tendencies,  may  also  occur  a  day  or  two  later. 
The  next  signal  of  importance  is  sleeplessness.  This  is 
found  in  a  great  many  cases  to  have  been  persistent  from 
the  time  of  childbirth,  and  to  have  had  a  serious  influence 
in  producing  insanity.  Another  very  important  symptom  is 
bad  dreams.  Fears  and  anxieties  take  hold  of  the  mind ;  a 
very  little  matter,  a  casual  remark,  which  at  any  other  time 
would  have  no  significance  whatever,  is  seized  on  with 
morbid  avidity,  and  influences  the  state  of  feeling  of  the 
patient,  reappearing  in  the  most  grotesque  form  in  her 
dreams.  For  this  reason  no  unpleasant  suggestions  should 
be  made  in  presence  of  nervous  patients. 

A  further  symptom  which  should  be  carefully  noted  is 
extreme  restlessness  and  irritability.  These  might  be  reckoned 
of  little  account ;  but  that  is  a  mistake,  because  they  are 
often  the  first  signs  of  the  coming  storm.  They  are  grave 
if  attended  with  failures  of  memor};^  and  speech.  In  some 
cases  we  are  made  suspicious  of  coming  mischief  if  the  patient 
is  the  subject  of  an  unaccountable  dread,  a  vague  nervous 
fear  visible  in  the  expression  of  the  eye,  often  appearing 
during  the  fourth  or  fifth  day,  and  a  sign  which  must 
cause  anxiety.  This  morbid  fear  is  the  fear  of  something 
about  to  happen,  in  some  cases  a  fear  that  reason  is  giving 
way,  and  the  patient  about  to  lose  her  normal  consciousness 
and  self-control.  The  first  sign  of  indifference  to  husband 
or  child,  or  any  relative  to  whom  she  was  previously  attached, 
should  be  regarded  as  unfavourable.  Of  physical  signs  there 
are  many  which  may  not  lead  to  puerperal  insanity;  but 
in  nervous  cases  they  may,  and  ought  to  be  taken  note 
of.  These  are  headaches,  rigors,  feverish  attacks,  acute 
diseases,  and  albumen  in  the    urine.     Careful  attention  to 


PUERPERAL  INSANITY 


the  physical  well-being  of  the  patient  is  of  the  utmost  im- 
portance. 

Maniacal  Form. 

The  Symptoms  of  the  Fully -developed  A  ttack.  —  Puerperal 
insanity  may  appear  in  any  of  three  forms — mania,  melan- 
cholia, or  stupor.  It  may  be  said  here  in  passing,  and  then 
the  subject  is  dismissed  for  good,  that  general  paralysis  does 
appear,  though  it  is  extremely  rare  during  pregnancy  or  the 
puerperal  state.  The  old  term  applied  to  insanity  at  this 
period  was  puerperal  mania.  It  was  the  only  conception  of 
the  older  writers  on  the  subject,  and  it  was  so  far  justified 
in  this,  that  mania  is  much  the  most  common  of  the  forms 
which  this  disease  assumes.  It  is  true  that  melancholia  is 
by  no  means  unknown,  and  it  may  be  that  some  of  the  cases 
tabulated  as  melancholia  by  one  writer  would  be  tabulated 
as  mania  by  another. 

Be  that  as  it  may,  true  puerperal  insanity,  by  which  I 
mean  insanity  coming  on  within  a  month  after  labour,  takes 
in  the  great  majority  of  cases  maniacal  forms.  In  some 
cases  it  is  a  feverish,  impulsive  mania,  a  delirium  which  is 
rather  suggestive  of  delirium  tremens,  except  that  it  is  not 
attended  by  tremor.  In  some  instances  the  observer  is 
reminded  of  the  latter  disease  by  an  expression  of  nervous 
tension  and  anxiety,  and  an  attitude  of  fear  with  efforts  to 
escape,  a  transient  or  more  persistent  delirium,  a  wild, 
unkempt  look,  delusions  of  apprehensive  character,  and  the 
presence  of  hallucinations  of  sight  and  hearing,  all  which 
may  be  observed  in  the  same  individual.  Profane  and 
indecent  speech,  erotic  conduct,  exposure  of  the  person, 
were  formerly  described  as  almost  invariable  concomitants 
of  the  disease ;  but  our  experience  is,  and  it  is  confirmed  by 
Wiglesworth  and  others,  that  this  certainly  is  not  by  any 
means  constant,  and  may  be  often  witnessed  in  cases  with- 
out a  history  of  parturition  at  all.  The  mind  wanders,  and 
it  is  difficult  to  arrest  attention.  In  some  always,  and  in 
others  between  the  paroxysms,  it  may  be  possible  to  fix  the 
attention  ;  but  in  all  cases  brain  action  is  feeble,  and  the 
mental  result  is  trifling  and  childish. 

21  —  2 


324  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

Impulsiveness,  sheer  recklessness,  mischievous  impulsive- 
ness, is  a  common  feature  of  puerperal  mania.  This  im- 
pulsiveness is  rarely  treacherous,  and  it  is  attended  with 
a  reckless  indifference  to  consequences.  It  is  frank, 
childish,  good-natured,  and  comes  often  in  unexpecj;ed 
paroxysms.  At  the  same  time,  it  may  proceed  from  halluci- 
nations, and  as  they  are  exceedingly  common,  the  nurse 
should  be  ever  on  the  outlook,  and  not  trust  her  patient  for 
a  second.  The  excitement  may  be  actually  delirious,  a  state 
of  raving  incoherence,  which,  if  we  read  between  the  lines, 
may  yet  have  an  unmistakable  meaning.  As  a  rule,  how- 
ever, the  patient  is  not  so  incoherent  as  this  ;  there  are 
intervals  of  lucidity  and  paroxysms  of  excitement.  Puerperal 
mania  is  frequently  paroxysmal  in  its  character,  all  the  more 
so  if  it  is  correlated  with  distinct  physical  signs  of  disease. 
When  it  is  less  complicated  in  this  way,  it  may  be  more 
continuous  in  its  exhibitions,  but  in  extreme  cases,  with 
hyperpyrexia,  acute  delirious  mania  may  persist  for  weeks. 

Hallucinations. — Hallucinations  of  the  senses  may  be 
present,  but  the  sensation  of  hearing  is  in  addition  par- 
ticularly acute,  and  these  patients  seem  to  respond  to  the 
very  faintest  sounds,  or  to  remarks  spoken  in  a  low  tone, 
and  not  directly  addressed  to  them.  Their  senses  seem  to 
be  acutely  receptive  and  continually  on  the  alert,  so  that  any 
slight  disturbance  seems  to  be  an  intense  sensory  stimulus. 
Hallucinations  are  almost  invariably  present  in  all  cases, 
those  of  hearing  and  sight  being  most  frequent  ;  but  halluci- 
nations of  the  other  senses  are  not  uncommon.  One  patient 
would  start  suddenly  as  if  she  heard  a  sound,  and  call  out, 
'There,  he  is  coming!'  Another  saw  people  trying  to  burn 
themselves,  while  a  third  experienced  a  smell  of  gas,  and  saw 
gas-meters  coming  in  at  the  window. 

Delusions. — Delusions  may  be  ill  formed  and  ill  expressed, 
mere  delirious  expressions  in  feverish  cases,  or  they  may  be 
of  more  serious  omen,  and  be  more  or  less  persistent  for  a 
time.  They  are  frequently  exalted,  and  may  at  the  same 
time  be  associated  with  ideas  of  persecution.  One  common 
delusion  which  has  been  observed  by  several  writers  on  the 
subject  is  centred  in  the  idea  of  maternity,  and  is  rare  in 


PUERPERAL  INSANITY  325 

other  forms  of  insanity.  It  is  that  the  patient  is  the  Virgin 
Mary,  or  that  someone  else  is.  Thus,  one  patient  asserted 
that  her  nurse  was  Mary,  the  Mother  of  God.  Other 
delusions,  variations  of  this,  are  that  the  patient's  baby  is 
Mary,  called  after  the  Virgin  Mary,  or  that  the  patient  her- 
self is  the  wife  of  Christ.  One  woman  talks  frequently 
about  the  Virgin  Mary,  and  says  that  her  baby  is  to  be 
called  John,  the  beloved  disciple.  These  and  other  examples 
which  might  be  quoted  illustrate  the  maternal  basis  of  exalted 
religious  delusions. 

Exalted  delusions  refer  also  to  other  Bible  characters,  e.g., 
Mother  Eve,  and  the  Queen  of  Sheba,  though  many  have 
no  scriptural  connection  at  all.  One  lively  young  wife 
skipped  about  like  a  dancing-girl  and  called  herself  '  the 
daughter  of  the  regiment,'  and  a  patient  much  reduced  from 
septicaemia,  and  the  discharge  from  several  abcesses,  enter- 
tained the  delusion  that  a  large  sum  of  money  had  been  left 
to  the  institution.  In  one  case  the  delusions  were  that  the 
doctor  was  the  Duke  of  Edinburgh,  and  the  patient  '  the 
lad)^  of  the  house.'  Delusions  of  persecution,  abuse,  and 
suspicion  are  quite  consistent  with  the  maniacal  state.  One 
patient  declared  that  her  sister-in-law  had  murdered  her 
baby,  that  she  had  been  abused  and  ill-treated,  that  she  was 
a  queen  and  the  doctor  a  king.  Another  believed  her  father 
was  murdered,  and  she  was  very  dangerous  to  those  nurses 
and  patients  who  were  the  malevolent  creatures  of  her 
delusions.  Withal  she  believed  herself  to  be  a  very  great 
and  titled  lady. 

Other  delusions  refer  to  the  husband.  One  wife  said  he 
was  a  sinner,  and  lifted  the  poker  to  him.  In  some  of  these 
instances — and  probably  the  melancholic  form  illustrates 
this  best — there  was  some  foundation  for  aversion  to,  if  not 
delusions  regarding  the  husband.  Undoubtedly  the  sexual 
feeling  is  perverted  in  many  cases.  The  law  of  action 
and  reaction  shows  it  in  everyday  life,  not  only  in  the 
extremes  of  sexual  feeling,  but  in  other  extremes  as  well,  and 
therefore  we  need  not  be  surprised  to  find  wives,  to  say  the 
least,  indifferent  to  their  husbands,  if  not  actually  hating 
them. 


326  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

Masturbation  is  not  frequent,  although  this  symptom  has 
been  made  much  of  by  some  writers  ;  indeed,  it  is  difficult  to 
understand  how  it  should  be  on  psychological  grounds  alone. 
When  it  is  present,  it  is  rather  the  result  of  peripheral  irrita- 
tion, and  when  this  is  attended  to  it  usually  ceases. 

Delusions  of  identity  are  very  prevalent  :  doctors  and  nurses 
have  new  names  given  to  them,  for  the  patient  does  not 
realize  the  changed  condition  of  things.  The  people  around 
the  patient  are  usually  recognised  as  being  of  great  im- 
portance, and  the  names  assigned  to  them,  secular  or 
religious,  indicate  the  exalted  bias  of  the  patient. 

Homicidal  and  Suicidal  Propensities. — These  are  present 
separately  or  combined  in  at  least  a  third  of  the  cases,  but  I 
have  not  found  them  deliberate,  vicious,  or  well  directed  as 
a  rule.  The  most  dangerous  and  most  vicious  attacks  are 
on  the  husband  especially,  but  sometimes  also  on  the  child. 
The  suicidal  propensity  has,  moreover,  to  be  reckoned  as 
quite  a  possible  and  impulsive  symptom  of  the  disease ;  but 
we  must  look  for  it  in  its  really  deliberate  and  purposive 
character  in  the  melancholic  form  of  the  disease. 

Pyromania. — A  morbid  impulse  to  burn  things  may  be 
noticed  in  not  a  few  puerperal  cases.  This  symptom  has  not 
been  referred  to  in  the  literature  of  the  subject,  so  far  as  I 
am  aware,  but  I  have  carefully  investigated  the  subject,  and 
ascertained  beyond  doubt  its  presence  in  some  form  or  other 
in  quite  a  number  of  cases  of  mania.  In  many  cases  the 
motive  assigned  was  a  bad  smell,  but  in  others  it  was  a  result 
of  wanton  mischief.  Clothing,  sheets,  curtains,  the  patient's 
own  apparel,  were  the  articles  usually  burned.  Halluci- 
nations of  smell,  though  sometimes  associated  with  this 
symptom,  were  not  detected  in  all  the  patients  so  disposed. 

Stiipor. — -Nothing  that  exhibited  a  dissimilarity  to  stupor 
in  general  has  come  under  my  notice,  and  anything  specific 
in  the  character  of  the  disease  is  due  to  the  puerperal  history 
and  associated  physical  conditions. 

The  chief  cases  of  stupor  in  my  experience  were  those 
following  attacks  of  excitement.  The  state  of  stupor  is 
usually  preceded  by  a  short  attack  of  excitement,  often 
hysterical    in    character,    sometimes  acutely    maniacal,  and 


PUERPERAL  INSANITY  327 


sometimes  melancholic.  Mentally  there  is  want  of  vigour,  a 
slowness  m  comprehending  and  answering  questions,  an  ex- 
pression of  vacancy,  and  muscular  flaccidity.  Delusions  may 
exist  in  the  condition  of  stupor  if  of  the  melanchohc  form, 
but  their  presence  is  judged  of  by  conduct  rather  than 
speech.  The  stupor  does  not  endure  long — that,  at  least,  is 
my  general  experience.  We  have  found  it  continue  for  some 
months  in  a  few  cases,  but  more  often  a  few  weeks,  the  eyes 
taking  on  expression,  the  muscles  hardness,  a  quicker  respon- 
siveness appearing,  for  the  reaction-time  is  accelerated,  the 
appetite  becoming  better — though  in  the  state  of  stupor  some 
are  voracious — and  the  patient  beginning  to  take  an  interest 
in  things  and  to  engage  in  some  employment. 

Changed  Affections  and  Sexual  D elusions. ^One  peculiarity 
which  runs  through  almost  all  cases,  whether  mania  or 
melancholia,  is  the  morbid  distrust  of  the  husband.  This 
strong  suspicion  seems  to  be  the  most  deeply-rooted  of  all 
the  mental  symptoms  of  puerperal  insanity.  I  have  known 
a  patient,  mentally  sane  in  all  other  respects  for  months, 
still  refuse  to  live  with  her  husband,  without  any  shadow  of 
moral  excuse  whatever. 

Melancholic  Form. 

Looking  over  the  notes  of  the  melancholic  cases,  I  find  no 
exception  to  this  almost  general  rule  which  I  have  just  stated; 
if  anything,  they  were  worse,  and  one  and  all  suspected  their 
husbands  of  improper  intercourse  with  the  nurses  in  charge 
of  them.  Such  patients  are  often  suspicious  of  the  medicine 
and  food,  believing  that  they  contain  poison,  whether  given 
by  the  husband  or  by  strangers.  The  suicidal  element  is 
often  strong,  and  the  act  is  frequently  attempted.  Delusions 
of  a  religious  nature  are  the  usual  rule.  One  patient 
imagined  the  devil  was  inside  of  her  ;  another  declared  that 
she  was  in  hell,  and  that  at  night  the  devil  came  and  put  his 
clutches  on  her  face,  and  that  she  heard  his  chains  rattling 
(there  was  here  a  combination  of  delusions  and  halluci- 
nations). Hallucinations  are  very  common.  One  melan- 
cholic patient  declared  that  she  saw  a  dead  woman  sitting 
on  her  bed,  and  at  another  time  that  she  saw  men  taking 


328  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

her  sister  away  in  a  cab.  Although  the  melancholic  is,  as 
a  rule,  sanely  conscious  of  many  things,  and  usually  coherent, 
there  may  be  incidental  flights  of  delirium  in  the  course  of 
the  case,  as  in  the  following  instance :  A  clot  in  the  uterus 
gave  rise  to  the  delusion  that  another  baby  was  coming  ;  the 
patient  got  frightened,  confused,  and  delirious ;  the  clot 
came  away,  the  calmer  state  returned. 

Bodily  Symptoms  in  all  Forms. 

These  are  very  much  in  evidence  in  very  many  cases,  and 
it  is  no  exaggeration  to  say  that  on  successful  treatment  of 
somatic  conditions  depends  the  cure  of  nearly  every  case  of 
puerperal  insanity. 

The  general  appearance  is  very  striking  in  by  far  the 
majority  of  those  admitted  with  this  disease.  It  is  almost 
possible  to  diagnose  the  case  as  one  of  puerperal  or  lactational 
insanity  at  the  outset.  The  only  diseases  that  may  appear 
to  resemble  it  are  delirium  tremens  or  acute  delirious  mania. 
The  eyes  are  generally  sunken,  with  dark  rings  round  them  ; 
the  expression  is  haggard,  the  brows  are  contracted,  and  the 
general  appearance  is  one  of  emaciation  and  exhaustion.  I 
do  not  know  why  it  should  be  so,  but  I  have,  in  a  long  experi- 
ence, after  careful  statistical  inquiry,  found  brown  eyes  inore 
frequently  associated  with  this  disease  than  blue  or  gray, 
although  with  the  latter  two,  other  forms  of  insanity  are  quite 
as  frequently  associated  as  with  brown  eyes,  if  not  more  so, 
and  probably  they  are  more  common  in  the  general  population 
of  this  country.  It  is  perhaps  the  case  that  in  brown-eyed 
patients  there  is  more  nervous  excitabilit}',  although  mentally 
they  may  be  as  well  balanced  and  self-controlled. 

Lochia  and  Milk. — At  or  about  the  time  of  the  onset  of  the 
mental  attack,  the  lochia  is  usually  scanty  or  suppressed,  and 
unnaturally  offensive  ;  but  in  some  cases  it  is  profuse  and 
very  offensive.  The  milk  is  suppressed  in  a  very  large  per- 
centage, it  is  rarely  plentiful ;  the  state  of  the  bowels  was 
costive  or  obstinately  costive  in  70  or  80  per  cent. ;  diarrhoea 
occurs  rarely.  Fasces  are  frequently  dry,  hard,  and  dark  in 
colour  ;  and  rarely  clay-coloured. 


PUERPERAL  INSANITY  329 

The  Urine. — The  urine  has  been  examined  with  more  than 
perfunctory  interest  since  the  late  Sir  James  Simpson  directed 
attention  to  the  prevalence  of  albuminuria  at  the  outbreak  of 
puerperal  insanity.  That  it  has  any  causal  relation  is  not 
now  entertained,  nor  have  I  found  any  recent  support  which 
can  confirm  the  view  of  Ludwig  Hoche  and  others,  that 
uraemia  is  an  important  cause  (Archiv  filr  Psychiatrie  itnd 
Nervenkrankheiten,  1892).  That  an  arrest  of  any  of  the  renal 
secretions  can  account  materially  for  the  onset  of  the  disease 
is  an  idea  which  is  not  now  considered  a  likely  explanation 
of  the  causation  of  puerperal  insanity. 

The  urine  is  scanty  in  maniacal  cases,  and  in  all  feverish 
conditions  accompanying  the  disease.  The  lowest  amount 
registered  in  twenty-four  hours  was  6  ounces,  and  this  had 
to  be  drawn  off.  In  seventeen  cases  carefully  observed,  the 
average  total  for  twenty-four  hours  during  the  first  three 
days'  residence  in  the  asylum  was  i6"6  ounces.  These  figures 
are  all  the  more  striking  when  we  consider  how  frequently 
the  skin  was  dry,  the  bowels  constipated,  and  the  various 
secretions  diminished.  Albumen  is  not  found  after  the  first 
few  days,  except  there  be  renal  disease  ;  but  it  is  frequent  in 
its  appearance  at  the  onset  of  the  attack,  and  perhaps  when 
it  is  imminent,  though  of  this  latter  I  have  no  experience. 
Bile  is  rarely  present,  though  the  sallow  appearance  of  the 
skin,  and  som.etimes  a  saffron  colour,  might  suggest  its 
existence.  Chlorides  are  diminished  in  all  febrile  states,  and 
of  course,  where  the  quantities  of  liquor  are  so  small,  one 
naturally  expects  the  solids  to  be  diminished.  The  lowest 
record  of  urea  excretion  was  3*68  grammes  in  twenty-four 
hours,  the  average  health  quantity  being  from  30  to  40 
grammes.  The  urine  increases  in  quantity  in  a  very  few 
days,  especially  if  the  patient  takes  her  food  fairly  well. 

Visceral  or  Constitutional  Complications. — Puerperal  mania 
is  often  ushered  in  (especially  among  the  poorer  classes)  by 
rigors,  inflammation,  or  septicaemia.  As  to  the  diagnosis  of 
septicaemia,  it  must  be  admitted  that  there  is  often  a  difficulty 
in  making  sure  of  a  local  and  primary  seat  of  infection,  and 
particularly  so  when  dealing  with  insane  patients.  For  one 
thing,  the  cry  of  pain,  or  its  absence,  must  not  be  implicitly 


330  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

relied  on.  Patients'  cries  of  pain  are  sometimes  misleading ; 
the  mental  equation  must  be  taken  into  account.  The  bowels 
should  be  thoroughly  evacuated  before  an  attempt  is  made 
to  settle  the  question.  Even  then  the  restlessness  of  the 
patient  will  disturb  and  distract  attention,  and  as  the  septic 
lesion  is  often  slight  enough  to  elude  the  tactile  sense,  it  may 
be  missed  altogether.  Sudden  rises  of  temperature,  whether 
preceded  by  a  chill  or  not,  will  often  perplex  the  physician. 
They  may  be  septicsemic,  phthisical,  zymotic,  neurotic,  or 
simply  inflammatory,  and  they  may  refer  purely  to  intestinal 
causes.  Zymotic  disease  will  soon  settle  the  question,  so  far 
as  it  is  concerned  ;  and  so  will  phthisis,  unless  it  is  of  the 
insidious  tubercular  form.  But  the  differential  diagnosis  of 
the  others  is  not  so  easy;  and  in  one  case  of  periodic  pyrexia, 
I  had  difficulty  in  deciding  between  hepato-intestinal  disorder 
and  septicaemia.     It  turned  out  to  be  the  former. 

Next  in  importance  to  septicaemia  and  its  congeners  is 
phthisis  pulmonalis.  Batty  Tuke  records  three  cases  of  death 
from  phthisis  out  of  seventy-three  patients  labouring  under 
puerperal  insanity,  and  the  late  Dr.  Boyd  reported  two  out  of 
sixty-three.  My  number  is  three  out  of  sixty.  Bronchitis, 
pneumonia,  and  heart  disease  have,  so  far  as  my  statistics  go, 
been  less  frequent,  but  they  are  recorded.  Mammary  abscess 
was  a  complication  of  two  cases  of  melancholia  under  my 
care.  The  abnormal  conditions  of  the  primae  viae  have  been 
already  referred  to. 

Rarely  was  a  recent  case  admitted  that  did  not  exhibit 
uterine  or  allied  symptoms  of  abnormal  character,  the  most 
frequent  being  pain  on  pressure  in  the  hypogastrium,  and 
scanty,  extremely  offensive  lochia.  Precision  of  examination 
was  not  always  possible  ;  but  if  accuracy  of  diagnosis  was 
not  assured,  the  certainty  of  some  form  of  uterine  or  allied 
disease  was  frequently  established.  Three  cases  studied 
post-mortem  showed  pelvic  inflammation,  and  a  dirty  sloughy 
placenta  site  in  a  typhoid  case.  One  patient  who  recovered 
had  pelvic  cellulitis  ;  another  retention  of  clots  in  the  uterus, 
with  high  fever  and  deeply-seated  pain  in  the  right  iliac  region; 
while  a  third  complained  only  of  tenderness  on  pressure  over 
the  uterus.     These  are  fair  illustrations  of  many  other  cases 


PUERPERAL  INSANITY  331 

which  might  be  quoted,  and  suffice  to  show  the  importance 
of  attending  to  the  condition  of  the  uterus  and  other  pelvic 
organs. 

Etiology. 

I  have  already  referred  to  the  influence  of  heredity  in  the 
production  of  puerperal  insanity,  but  there  are  more  specific 
incidents  which  must  not  be  overlooked,  as  they  have  a 
bearing  on  the  prevention  of  the  disease  even  where  there 
is  a  hereditary  indisposition.  Mental  depression  during 
pregnancy,  or  as  a  result  of  causes  appearing  at  or  about  the 
puerperal  period,  may  be  reckoned  as  an  antecedent  in  some 
cases.  There  are  often  such  moral  causes  as  illegitimacy, 
desertion  by  the  husband,  bereavements,  and  so  forth  ;  in- 
sanitar}^  conditions  are  very  prejudicial,  and  of  course  there 
are  many  incidents  of  the  puerperum  which  must  have  a 
depressing  effect  on  the  patient.  To  these  may  be  added 
the  injudicious  attention  of  friends,  too  many  visitors,  and 
want  of  sleep.  Septic  absorption  has  been  credited  with 
being  a  considerable  factor  in  the  production  of  puerperal 
insanity.  In  some  cases  I  have  found  septicaemia  and  in- 
sanity develop  almost  coincidentally,  and  except  on  the 
theory  of  direct  nervous  propagation,  a  reflex  excitement 
propagated  from  the  septic  focus,  it  was  difficult  to  prove 
the  relations  of  cause  and  effect.  In  one  series  of  cases  it 
was  evident  that  septic  absorption  appreciably  preceded  the 
mental  outbreak  ;  while  in  another  series  it  was  quite  evident 
that  the  mental  symptoms  were  pre-existent,  and  became 
intensified  after  the  inception  of  the  septic  process,  I  have 
found  scarlatina  and  typhoid  associated  with  puerperal  in- 
sanity, and  in  my  experience  the  clinical  phenomena  of 
these  respective  exanthematous  types  were  not  accurately 
produced  in  either  case.  Alcohol  is  a  blood  poison  which 
must  be  specially  virulent  in  its  action  on  the  brain  of 
puerperal  patients.  In  the  lower  ranks  of  life,  alcohol  is  a 
favourite  prescription  with  the  patient  and  her  friends,  and  I 
have  clear  evidence  of  its  influence  in  precipitating  puerperal 
insanity  in  two  cases.  It  is  probable,  however,  that  this 
craving  and  indulgence  in  some,  if  not  in  most,  of  the  cases 


332  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

was  a  symptom  of  dipsomania,  and  as  such  one  of  the  first 
symptoms  of  puerperal  insanity. 

There  are  many  acquired  brain  conditions  which  may 
precede  and  aid  in  developing  puerperal  insanity,  and  which 
might  properly  be  dealt  with  here.  Such  are,  for  example, 
epilepsy,  brain  injury  and  meningitis  ;  but  as  they  have  only 
a  rare  connection  with  puerperal  insanity,  they  need  not 
occupy  further  notice. 

Prognosis. 

The  prognosis  is  usually  good.  The  now  classical 
aphorism  of  Gooch,  that  '  mania  is  more  dangerous  to  life, 
and  melancholia  to  reason,'  is  not  borne  out  by  later  ex- 
perience. I  have  found  a  very  large  proportion  of  cases 
of  mania  recover,  and  I  have  found  melancholia  in  several 
cases  associated  with  disease  which  led  to  a  fatal  termina- 
tion. In  a  large  experience  of  this  disease,  of  which  I  have 
kept  exhaustive  records,  I  find  the  percentage  of  recoveries 
exceeds  80  per  cent.  A  rapid  pulse  used  to  be  regarded 
as  of  rather  bad  omen  ;  but  it  is  not  necessarily  so,  neither 
is  a  high  temperature,  if  it  is  not  long  continued.  To 
gauge  the  gravity  of  a  high  pyrexia  with  greater  precision, 
we  must  ascertain  the  average  morning  and  evening  tempera- 
ture during  the  acute  stage  of  the  disease.  Seeing  that  it  is 
the  pace  that  kills,  we  are  led  to  inquire  which  cases  exhibit 
in  toto  the  highest  temperatures  and  what  is  the  result  in 
these  cases.  It  will  be  found,  where  the  average  temperature 
for  several  days  is  maintained  at  102°  or  above  it,  the  prog- 
nosis must  be  very  grave.  An  average  temperature  of  ioi"5°, 
extending  for  a  period  of  six  weeks,  was  followed  by  recovery. 
If  phthisis  complicates  the  case,  the  prognosis  is  grave,  for  it 
appears  to  take  on  a  som.ewhat  acute  form  when  intercurrent 
with  the  insanity  of  the  puerperal  state.  Septicaemia  is  not 
necessarily  a  disease  of  bad  omen,  and  I  have  had  great 
satisfaction  in  the  treatment  of  this  condition.  One  patient 
had  several  large  abscesses  in  the  arms  and  thighs,  and  pelvic 
cellulitis,  all  of  which  were  opened  and  treated  with  antiseptic 
rigor,  with  a  very  satisfactory  result.  It  is  only  right  how- 
ever to  admit  that  some  of  the  cases  of  septicaemia  were  too 


PUERPERAL  INSANITY  333 

severe,  of  too  typhoid  a  type,  and  too  far  removed  from  the 
reach  of  surgical  treatment,  to  hold  out  much  hope  of 
recovery.  Granted  an  excellent  digestion,  good  staying 
power,  a  septicaemia  coming  within  the  surgeon's  province, 
and  the  prognosis  should  be  fairly  good.  Very  rarely  does 
the  disease  pass  into  a  chronic  condition  of  mania  or  dementia, 
unless  there  has  been  a  previous  history  of  mental  disease  or 
alcoholic  indulgence. 

Treatment. 

It  is  clear  from  the  foregoing  facts  that  no  simple  and 
specific  lines  of  treatment  can  be  laid  down,  for  there  is  an 
endless  variety  of  feature  presented  by  the  disease.  It  is, 
therefore,  desirable  to  classify  in  this  connection  according 
as  one  or  more  of  the  following  morbid  states  gives  a  pro- 
nounced character  to  the  disease.  The  fact  that  these  may 
blend  together  with  other  abnormal  states  in  one  and  the 
same  patient  is  clearly  understood,  but  they  are  now  separately 
identified  as  being  the  conditions  most  frequently  and  urgently 
calling  for  specific  attention. 

I.  Digestive,  Hepatic,  and  Intestinal  Disorders. — One  patient 
was  fed,  owing  to  refusal  of  food,  by  the  stomach-pump, 
with  rare  intermissions  of  voluntary  alimentation,  for  eight 
weeks.  The  tongue  and  the  roof  of  the  mouth  were  coated 
with  creamy  fur,  the  lips  were  cyanotic  and  crusted,  the 
saliva  white  and  inspissated,  often  frothy,  the  pharynx  re- 
laxed, the  stomach  irritable,  the  faeces  dry,  dark  or  greenish, 
and  slimy.  Septicaemia  with  diaphragmatic  and  pleuritic 
deposits,  and  boils,  complicated  the  case.  She  was  fed 
liberally  with  custards  (two  eggs  in  each),  beef-tea,  milk,  and 
whisky.  Calomel,  one  grain  bis  die,  and  Acid.  Nit.  Mur. 
Dil.,  with  Tr.  Nucis  Vomicae,  ter  die,  were  administered,  the 
calomel  powders  being  intermitted  at  the  end  of  three  days, 
to  be  repeated  as  occasion  suggested.  Castor-oil  was  pre- 
scribed from  time  to  time  with  good  effect.  Cod-liver-oil 
was  given,  and  for  a  month  she  was  under  mild  Bromide 
of  Potassium  treatment.  Result  after  three  weeks,  during 
which  occurred  two  moderate  pyrexial  crises  :  She  still 
refused  food  ;  the  tongue  and  mouth  cleared  up  a  little,  and 


334  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

then  got  heavily  furred  again ;  the  appetite  returned  for  a 
day  only  once,  and  she  was  getting  so  weak  as  to  threaten 
collapse  during  feeding.  Cod-liver-oil  was  stopped,  then 
custards,  then  bromide,  and  last  of  all  artificial  feeding,  but 
neither  of  these  changes  of  treatment  seemed  to  encourage 
a  healthier  state.  The  stomach  was  now  evacuated  from 
time  to  time  to  ascertain  the  progress  of  digestion,  and 
after  three  and  a  half  hours  custards  were  withdrawn  little 
altered  in  bulk  or  character  from  the  hour  of  injection. 

Her  weight  was  now  taken — 6  stones  2  pounds  (86  pounds) 
— the  stomach  was  washed  out  with  i  in  500  carbolic  lotion, 
and  a  diet  scale  arranged,  to  be  pumped  (after  predigestion 
with  Benger's  liquid  pepsine)  at  intervals  of  four  hours  four 
times  a  day.  The  diet  was  thus  prepared  :  8  a.m.,  f  pint 
milk,  with  one  egg  as  a  custard  ;  12  noon,  f  pint  beef-tea, 
with  finety-grated  potato  in  suspension  ;  4  p.m.,  custard  as 
at  8  a.m. ;  8  p.m.,  f  pint  milk  gruel;  2  ounces  whisky  were 
given  in  twenty-four  hours.  No  medicines  given.  She 
lost  5  pounds  in  the  first  week.  Bismuth  was  now  pre- 
scribed, and  a  combination  of  the  bromides  of  potassium  and 
ammonium.  Up  to  this  time  food  regurgitated  in  an  undi- 
gested state  on  introduction  of  tube,  hence  the  bismuth  treat- 
ment. At  the  end  of  the  second  week  she  had  lost  4  pounds, 
and  seemed  on  the  whole  better  under  bis-bromide  combina- 
tion ;  but  at  the  end  of  the  third  week  this  was  given  up,  as 
lips  and  tongue  were  becoming  more  dry,  and  a  copious  rash 
had  appeared.  The  pyrexial  crises  were  less  marked  during 
these  three  weeks. 

At  the  end  of  the  third  M^eek  the  weight  was  stationary.  The 
tri-bromide  combination  of  potassium,  sodium  and  ammonia 
was  tried,  and  suffered  a  like  fate  with  its  predecessors.  At  the 
end  of  the  fourth  week  the  weight  was  still  stationary.  She 
complained  of  diaphragmatic  pain  in  the  left  side,  and  had  a 
short  troublesome  cough  at  the  end  of  the  fifth  week,  with  the 
highest  temperature  yet  reached  (over  103°  for  two  days  and 
three  nights).  Eructations  and  regurgitation  of  food  had 
not  been  troublesome  for  some  days,  but  the  secretions  were 
very  scanty,  and  the  tongue  and  lips  were  dry,  so  that  the 
bromides  were  stopped. 


PUERPERAL  INSANITY  335 

At  the  end  of  the  seventh  week  her  weight  was  5  stones 
6  pounds,  and  she  had  lost  i  pound.  Later,  with  apparently 
more  gratif3'ing  effect,  Carnick's  peptonized  cod-liver-oil  and 
milk  were  tried  ;  but  this  might  have  been  a  case  of  post  hoc. 
I  judged  at  this  time  that,  although  the  '  turn  of  the  scale ' 
had  not  been  reached,  she  was  stronger,  less  limp  in  our 
hands,  and  less  cyanotic  during  the  artificial  feeding.  It 
ought  to  be  stated  that  the  method  of  alimentation  was  by 
means  of  the  soft  oral  tube,  that  four  nurses  were  at  hand,  each 
trained  to  a  particular  duty,  and  that,  from  the  first  handling 
to  the  last,  the  time  occupied  was  less  than  a  minute.  If  I 
had  such  a  case  again,  I  would  try  nutrient  and  stimulant 
enemata  as  well,  and  give  the  upper  digestive  tract  less 
work  and  irritation. 

From  this  period  onwards  she  slowly  recovered  ;  she  began 
to  take  her  food  herself,  but  in  very  small  quantities  com- 
pared with  what  had  been  injected  into  the  stomach  hitherto, 
sufficient,  however,  to  turn  the  scale.  Soon  she  was  able, 
the  weather  being  propitious,  to  go  out  into  the  open  air, 
and  in  two  months  had  risen  from  5  stones  6  pounds  to 
6  stones  9  pounds.  She  was  of  phthisical  habit,  had  not 
menstruated  three  months  after  recovery,  and  her  doctor 
then  wrote  me  that  she  was  under  treatment  at  home  '  with 
rusty  sputum  and  dulness  over  left  lung.' 

2,  Uterine  and  Hcemic  Treatment. — Intra-uterine  and  vaginal 
injections  often  do  good.  To  soothe  is  to  reduce  excitement 
and  promote  sleep,  and  uterine  medication  may  have  a  more 
direct  and  salutary  influence  on  the  mental  condition  than 
has  been  suspected.  Direct  uterine  injection  will  probably 
be  found  more  serviceable  than  mere  vaginal  irrigation  where 
there  is  fever  and  local  distress  with  signs  or  threatenings  of 
septicaemia.  Superficial  evidence  of  septicaemia  was  found  in 
abscesses,  boils,  scalp  deposits  often  resembling  wens,  and  a 
copious  pustular  acne.  It  is  unnecessary  to  linger  over  their 
appropriate  treatment. 

Constitutional  means  may  be  employed  in  two  directions  : 
{a)  to  increase  nutritive  processes,  {b)  to  arrest  fermentation. 
The  first  of  these  has  already  been  discussed,  and  in  addition 
to  its  more  immediate  purpose  of  bringing  up  nutrition  to  its 


336  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

normal  standard,  it  exercises  a  double  purpose  in  septicaemia 
by  also  increasing  physiological  resistance  to  degenerative 
change.  If  it  be  admitted  that  septicaimia  has  in  the  present 
instance  a  wider  meaning  than  that  of  a  mere  germ  disease  ; 
if  it  be  accepted  that  it  may  arise  from  the  diffusion  through 
the  primcB  vice  into  the  blood  of  putrid  gases,  or  from  retained 
and  decomposing  excreta  within  the  bloodvessels  absorbed 
from  puerperal  disintegrations,  or  from  the  retention  and 
accumulation  of  the  elements  of  secretions,  then  the  question 
is  one  not  only  of  germicide  but  depurative  treatment.  That 
septic  absorption  may,  secondarily,  carry  in  its  train  the 
absorption  of  lesser  impurities,  and  by  secondary  deposits 
induce  local  and  constitutional  changes  enough  to  account 
for  a  heterogeneous  septicaemia  such  as  I  have  described,  is 
possibly  or  approximately  true  ;  but  local  absorption  does  not 
always  take  place,  and  secondary  deposits  more  rarely  still. 
Septicaemia  has  many  grades,  and  often  tapers  into  the  finest 
and  least  nocuous  attenuations ;  yet  we  still  have  evidences 
of  grave  blood  impurity  arising  manifestly  from  the  sources 
above  indicated,  these  being  primary  and  independent  of 
septic  absorption. 

The  treatment  of  anaemia,  so  far  as  it  may  be  regarded  as 
specific,  was  confined  in  recent  and  extreme  cases  to  either 
enemata  of  defibrinated  blood  {vide  article  in  Lancet,  by 
Sansom,  vol.  i.,  1881)  or  Blaud's  pills.  The  treatment  of  the 
more  chronic  forms  was  chiefly  by  means  of  arsenic  and 
iron.  Defibrinated  blood  is  undoubtedly  of  value,  especially 
where  the  anaemic  state  has  been  induced  suddenly  and 
intensely. 

3.  Hysteria. — In  one  patient  a  quick  recovery  followed 
purgative  treatment ;  in  another  this  had  no  prominent  effect, 
and  a  definite  and  satisfactory  result  followed  the  exhibition 
of  bromide  of  potassium  (45  grains)  every  four  hours.  Copious 
diuresis  soon  followed,  and  in  three  weeks  the  patient  was 
convalescent.  I  had  hoped  to  find  in  bromide  treatment 
something  specific  for  the  hysteric  group,  but  the  cases  are 
often  too  asthenic,  and  my  one  good  result  was  exceptional. 
Certain  hysterical  cases  will  probably  benefit  in  this  way, 
but  there  must  be  no  flaccidity  or  inertia ;  rather,  there  must 


PUERPERAL  INSANITY  337 

be  acute  excitement,  distinct  nervous  tension  and  response 
to  reflex  stimuli. 

4.  Mania. — A  moment's  consideration  of  the  somatic 
relations  of  puerperal  insanity  will  suffice  to  show  that  there 
is  no  cutting  of  the  Gordian  knot  by  means  of  neurotic 
remedies,  unless  in  exceptional  cases  where  the  disease  has 
been  anticipated.  The  whole  mass  of  evidence  before 
us  leads  to  the  conclusion  that  treatment  must  be  of  a  varied 
character.  In  the  case  of  A.  B.  :  morphia  was  administered 
in  the  form  of  h  grain  suppositories  every  eight  hours,  with 
gastro-intestinal  correctives.  It  reduced  the  muscular  excite- 
ment, moderated  the  menidA  fur  ore,  did  not  arrest  the  cutaneous 
secretion  nor  diminish  appetite,  and  at  first  seemed  to  induce 
a  return  to  mental  stability  and  coherence.  Soon  the  mental 
habit  acquired  a  new  phase.  Previously  it  was  eccentric,  im- 
pulsive, explosive,  irrelevant,  invertebrate.  Good  nature 
and  playfulness  gave  place  to  sullen  obstinacy  and  dogged 
antipathies  ;  suspicions  and  delusions  of  persecution,  hitherto 
fleeting  and  superficial,  became  more  deeply  rooted  and  in- 
tensified. 

The  last  entry  in  the  case-book  regarding  this  patient, 
after  a  long  interval,  is  as  follows :  '  She  still  manifests 
strong  antipathies  to  all  the  nurses,  and  has  not  a  good 
word  to  say  of  anyone.  She  is  a  sour,  cross-grained  woman, 
and  yet  the  shadow  of  a  smile  betrays  that  she  is — even  at 
her  worst — not  so  severe  as  she  would  have  us  believe.  The 
morphia  treatment  does  not  seem  to  have  been  successful. 
It  has  prolonged  and  altered  the  morbid  habit,  rendering  her 
less  facile  and  amenable,  easily  put  out,  discontented,  never 
satisfied,  and  decidedly  cranky;  otherwise  she  is  coherent, 
knows  what  she  is  about,  has  no  definite  delusions,  and  will 
probably  do  well  at  home.  Three  weeks  later  she  was  dis- 
charged, considerably  subdued,  and  remained  out  for  several 
years.  In  another  case  the  suppositories  were  given  every 
eight  hours,  with  like  sudden  recovery,  but  followed  by  a 
relapse  to  a  worse  state.  She  did  and  said  silly,  childish 
things.  She  evinced  a  strong  animus  to  nurses,  and  on 
every  occasion  took  the  part  of  the  patients  against  the 
nurses,   believing   that   the   latter    invariably  abused  them. 

22 


338  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

Morally  she  was  utterly  depraved  in  her  ideas  ;  her  concep- 
tions of  right  and  wrong  were  of  the  lowest  character.  By- 
and-by  she  seemed,  after  a  close  study  for  some  weeks,  to  be 
free  from  delusions,  when  suddenly  she  expressed  the  delu- 
sion that  she  was  married.  Premonitory  epistaxis  ushered 
in  menstruation,  and  after  a  long  interval  she  gradual^  re- 
covered. I  have  since  discarded  morphia,  for  the  recoveries 
were  not  so  complete  as  they  might  probably  have  been 
otherwise,  and  convalescence  was  much  more  tedious  than  in 
our  usual  experience. 

The  effects  of  chloral  have  been  noticed  where  this  treat- 
ment was  pursued  prior  to  the  patients  coming  under  our  care. 
It  has  usuall}'  suspended  morbid  action  temporarily,  and 
even  induced  a  saner  perception  of  surroundings,  delusions 
of  identit}'  of  persons  and  place  having  vanished  for  a  time, 
and  a  pause  being  marked  in  the  course  of  the  excitement — 
an  ominous  pause,  however,  for  the  mental  excitement  became 
greater  than  before.  A  combination  of  Bromide  of  Potassium, 
25  grains,  with  20  of  Chloral  Hydrate,  I  have  used  as  a  hypnotic 
to  ward  off  exhaustion  from  prolonged  mental  excitement  and 
insomnia,  and  its  effect — a  good  one  in  itself — has  been,  after 
two  or  three  exhibitions,  to  restore  the  periodicity  of  sleep. 
As  to  any  specific  action  on  the  mental  state,  I  fear  this  com- 
bination has  none  ;  but  it  is  a  safer  hypnotic  and  sedative 
than  either  of  the  others. 

5.  Melancholia. — Morphia  was  given  in  one  case  of  melan- 
cholia— the  Liq.  Morph.  Mur.,  10  minims  four  times  a  day  for 
three  weeks.  The  appetite,  which  had  not  been  good  before, 
got  worse ;  she  refused  food,  and  the  mental  sj^mptoms  became 
intensified.  The  skin  was  all  along  dr}^  and  the  bowels 
costive.  At  the  commencement  of  morphia  treatment  a  pill 
was  prescribed  as  follows  : 

IjL  Ext.  nucis  vom.^ 

Ext.  belladon.     /^"^  ^'^'  ^• 
Ferri  sulph.,  gr.  ^. 
Pil.  coloc.  et  h3"oscy.,  gr.  i. 
Pill  mas.,  q.s. 
Sig.  :   One  or  more  dail}-  as  directed. 


PUERPERAL  INSANITY  339 

As  with  mania  so  with  melanchoHa :  there  is  no  fixed 
course  of  neurotic  treatment.  The  brain  nutrition  is  below 
par,  and  neurotic  drugs  are  not  brain  nutrients.  Till  nutri- 
tion is  restored  to  the  normal  standard,  there  cannot  be 
normal  function,  and  a  course  of  neurotic  treatment  in  many 
cases  is  decidedly  mischievous.  In  conclusion,  let  me  observe 
that  I  prescribe  :  (i)  The  open  air,  with  a  degree  of  exercise 
suited  to  the  strength  of  the  patient,  when  the  weather  is 
agreeable  or  the  walks  sheltered,  where  there  is  no  serious 
complication  and  the  patient  will  not  lie  in  bed ;  (2)  a 
private  room  with  a  nurse  to  herself,  when  she  keeps  in  bed, 
is  weak  and  exhausted,  and  suffers  from  pyrexia,  septicaemia, 
or  active  inliammatory  disease ;  (3)  above  all  things,  the 
utmost  quiet  and  isolation,  for  the  nervous  system  is  high- 
strung,  the  senses  are  most  acute,  and  intolerant  of  the 
slightest  disturbance.  Every  scrap  of  conversation  is 
suggestive  to  an  excited  puerperal  patient,  every  strange 
sight  or  sound  has  a  personal  meaning,  therefore  the  less 
suggestiveness  there  is  the  better.  This  is  the  sedative  treat- 
ment pa}'  excellence.  The  state  of  the  bowels  and  digestion 
are  of  the  very  first  importance  ;  but  in  their  treatment  no 
uniform  plan  can  be  laid  down,  for  in  these  respects  each 
case  is  very  much  a  law  unto  itself.  Several  useful  indica- 
tions have  been  already  stated  which  will  serve  as  guides  for 
different  classes. 


22- 


CHAPTER  XVI. 

PUERPERAL  AND  ALLIED  INSANITIES{contifiiied)— INSANITY 
OF  LACTATION. 

When  does  a  patient  come  under  the  category  of  lactational  cases  ? — 
Different  views  on  the  subject— Frequency  of  this  form  of  insanity 
more  noticeable  among  the  poorer  classes  —  JEtwXogy  —  Mental 
symptoms — Features  peculiar  to  the  melancholic  form,  and  those 
peculiar  to  the  maniacal  form — Physical  conditions — Prognosis — 
Treatment  — Clinical  illustrations  of  insanity  of  pregnancy — Puerperal 
insanity  and  insanity  of  lactation. 

Discrepancies  may  be  found  in  some  of  the  descriptions 
given  to  this  type  of  the  puerperal  series,  more  even 
than  the  others,  especially  in  general  text-books.  Playfair 
says  that  '  the  symptoms  of  these  various  forms  of  insanity 
are  practically  the  same  as  in  the  non-pregnant  state.' 
Others  see  very  little  difference  between  puerperal  insanity 
and  insanity  of  lactation.  The  fact  is  that  early  lactation 
cases  do  not  exhibit  the  marked  individuality  of  later  cases. 
Whilst  it  is  true  of  puerperal  as  well  as  of  lactational 
insanity,  that  exceptions  to  rule  are  by  no  means  infrequent, 
it  may  still  be  laid  down  as  a  general  rule  that  puerperal  cases 
are  usually  puerile  in  mental  character,  and  lactation  cases 
virile.  One  difficulty  in  dealing  with  the  subject  is  to  be 
found  in  the  following  question  :  '  When  is  insanity  occur- 
ring after  child-birth  no  longer  to  be  regarded  as  puerperal, 
and  how  soon  may  we  classify  a  case  as  one  of  insanity  of 
lactation  ?  If  a  month  or  six  weeks  is  to  be  the  limit  for  the 
appearance  of  what  we  call  puerperal  insanity,  is  a  case 
occurring  in  the  fifth  or  seventh  week  to  be  described  as  one 
of  insanity  of  lactation  ?  Clouston  gives  six  weeks  as  the 
technical  limit  for  puerperal  insanity,  Tuke  fixes  it  at  a 
month,  and  others  at  three  months.     Now,  when  we  consider 


PUERPERAL  AND  ALLIED  INSANITIES  341 

that  out  of  twenty-three  of  Clouston's  cases  seventeen  be- 
came insane  inside  six  months,  and  51  per  cent,  of  Tuke's 
cases  occurred  after  the  ninth  month,  it  is  not  surprising  if 
a  discrepancy  in  the  mental  character  of  these  two  series 
should  be  observed. 

Dr.  Tuke  allows  two  months  for  debatable  cases  which 
may  conform  either  to  the  puerperal  or  lactational  types.  . 
We  must  distinguish  between  cases  where  the  exhausting 
influence  of  lactation  is  the  preponderating  cause  and  those 
where  the  depressing  effects  of  parturient  and  puerperal  con- 
ditions are  still  maintained.  I  proposed  some  years  ago  at 
the  Glasgow  meeting  of  the  British  Medical  Association  that 
'  a  post-puerperal  period  of  two  or  three  months  should  be 
allowed  for  mixed  or  uncertain  cases.'  Where  for  a  series 
of  years  there  is  one  unbroken  chain  of  pregnancy,  parturi- 
tion, puerperium,  and  lactation  without  any  recuperative 
pause,  the  period  which  precipitates  an  attack  of  insanity  is 
only  the  last  straw. 

Frequency. — Among  the  opulent  classes  insanity  of  lacta- 
tion is  not  so  frequent  as  in  the  lower  ranks  of  life,  for 
obvious  reasons  ;  but  among  the  poorer  classes  it  is  certainly 
as  common,  perhaps  more  frequent  than  puerperal  insanity. 
This  statement  may  be  qualified  by  a  reference  to  Tuke's 
statistics,  which  give  the  preponderance  to  puerperal  in- 
sanity ;  but  it  is  questionable  if  puerperal  insanity  is  as 
frequent  as  it  was  during  the  period — thirty  to  forty  years 
ago — covered  by  these  statistics.  The  great  advances  in 
treatment  (antisepsis,  cleanliness,  skilled  medical  attendance, 
etc.)  have  diminished  the  risks  of  childbirth  considerably. 

Etiology. 

The  predisposition  to  this  form  of  mental  attack  may  be  a 
legacy  of  the  puerperal  state.  True  it  is  that  many  under- 
take nursing  with  an  eager  maternal  desire,  who  should  be 
strongly  dissuaded  or  firmly  obstructed  in  their  attempts  to 
do  so.  These  are  frequently  the  women  who  break  down. 
Another  group  is  that  numerous  set  in  the  poorer  walks  of 
life  who  seem  to  be  pregnant  or  nursing  mothers  all  the 
time,  who  toil  and  moil  all  their  married  life  through ;  while 


342  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

a  third  class  is  of  the  over-lactation  species,  suckling  to  pre- 
vent conception,  which  is  ruinous  for  mother  and  child.  It 
is  quite  a  usual  experience  to  admit  cases  who  have  suckled 
for  sixteen,  eighteen,  and  twenty  months.  Two  special 
depressants  must  be  clearly  recognised  —  the  exhausting 
drain,  and  what  Savage  lays  particular  stress  on,  the  act  of 
weaning  itself.  The  latter  is  often  a  worrying  and  nervously 
distressing  process  ;  the  child  will  not  give  up  the  breast, 
and  the  mother  is  sometimes  driven  frantic  between  two 
courses — to  yield  or  to  persevere.  Whatever  the  moral  or 
physical  explanation,  the  fact  remains  that  bodily  exhaustion, 
anaemia,  and  it  may  be  some  intercurrent  local  disease,  is 
usually  the  prelude  to  the  mental  outbreak.  In  my  experi- 
ence mammary  abscess  is  rare,  even  in  those  who  have  so 
suffered  in  this  way  before. 

The  Character  of  the  Mental  Outbreak. 

Usually  it  is  either  melancholic  or  maniacal,  the  former 
being  more  prevalent,  in  this  respect  differing  from  the  puer- 
peral period.  Stupor  is  sometimes  present,  but  it  is  quite 
infrequent.  Mania  and  melancholia  have  many  symptoms  in 
common,  physical  and  mental ;  the  two  are  here  described  to- 
gether to  begin  with,  and  the  differences  will  be  noted  later  on. 

In  either  case  it  is  noticed  that  the  attack  is  more  master- 
ful, persistent,  and  purposive  in  character  than  the  excite- 
ment of  the  puerperal  forms.  The  same  hatred  of  the 
husband,  less  explosive  and  effervescent,  more  persistent, 
malignant,  and  unforgetting,  is  seen  to  affect  the  whole 
character  and  conduct  of  the  woman.  The  child's  life  is 
often  in  danger,  and  as  much  so  in  the  hands  of  the  melan- 
cholic as  in  the  maniac,  but  for  different  reasons.  The  latter 
acts  from  delusion  or  illusion,  the  former  from  fear  and 
hallucination  ;  whilst  the  melancholic  is  not  afraid  to  destroy 
herself,  she  dreads  to  leave  a  living  child  behind  her.  She 
may,  however,  take  its  life,  in  obedience  to  a  commanding 
voice  (hallucination).  Sometimes  it  is  difficult  to  say 
whether  the  case  is  purely  melancholic,  for  the  fierce, 
relentless  passion  of  some  such  women  is  more  maniacal  in 
its  fury  than  anything  else. 


PUERPERAL  AND  ALLIED  INSANITIES  343 

Hallucinations.  —  These  are  usually  of  hearing  or  sight. 
The  patient  hears  her  children's  voices  somewhere  in  the 
asylum,  hears  her  mother  and  friends  upstairs,  or  hears  voices 
accusing  her.  One  woman  heard  the  devil's  voice  telling 
her  to  destroy  her  child.  Hallucinations  of  sight  are  very 
common,  as  the  following  extracts  show  :  '  She  sees  fish  and 
pigs  in  the  room,'  '  sees  figures  moving  about  her  bed,'  '  sees 
wasps  in  bed,  and  a  little  child  sitting  in  a  corner  of  the 
ceiling.'  Illusions  are  found,  though  more  rarely.  One  patient 
hugged  the  pillow  to  her  breast,  and  said  it  was  her  baby. 

Homicidal  and  Suicidal  Impulses. — One  patient  described  a 
feeling  as  if  her  inside  would  burst,  and  said  that  if  she 
could  only  get  someone  killed  she  would  be  relieved.  A 
patient  (maniacal)  acted  King  Herod,  with  her  child  in  one 
hand  and  a  knife  in  the  other ;  she  was  secured  in  time. 
The  husband  is  frequently  attacked,  and  one  woman  bit 
her  husband's  thumb  severely,  and  struck  her  sister  with  a 
poker.  Attempts  at  self-destruction  are  always  to  be  looked 
for,  especially  in  the  melancholic  state,  and  violence  may  be 
done  to  the  children. 

The  excitement  is  sometimes  paroxysmal,  often  very  intense 
and  oblivious,  the  patient  being  carried  away  beyond  herself 
into  a  state  of  fury,  sometimes  of  insane  rage,  masterful  and 
irresponsible.  In  a  few  cases  it  may  be  hysterical,  violent, 
noisy,  declamatory,  but  with  apparent  self-consciousness,  as 
seen  by  the  roving,  restless  eye,  which  all  the  time  looks 
knowing,  or  by  other  sensory  evidence,  and  by  the  purposive 
evidence  of  conduct  and  mental  symptoms  generally.  In 
one  the  breathing  on  medical  examination  was  hysterical  and 
sobbing  in  character,  the  pulse  120,  without  fever,  and  the 
patient's  urine  had  to  be  drawn  off  after  nineteen  and  a  half 
hours. 

The  bodily  health,  as  previously  indicated,  is  impaired. 
Various  abnormal  sensations  are  common.  One  lady  spoke  of 
a  rush  going  to  her  head,  and  then  all  was  darkness. 
Another  had  a  feeling  as  if  part  of  her  body  was  falling  out 
of  her.  A  third,  when  menstruation  came  on,  had  a  feeling 
as  if  her  head  were  growing  larger  and  her  nose  rising. 
Flushing  after  meals  is  noticeable,  and,  indeed,  the  state  of 


344  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

the  vascular  system  and  its  contents  is  at  the  root  of  many 
strange  sensations,  and  its  irregularities  of  supply  will  ac- 
count for  much  that  otherwise  would  be  incomprehensible. 
One  patient  who  was  most  sudden  in  her  movements, 
violent  and  wildly  excited,  while  in  a  warm  bath  was  re- 
stored to  reason  for  the  time  being,  realized  her  position, 
spoke  sensibly,  and  a  few  minutes  after  she  was  taken  out  of 
the  bath  became  as  wild  and  excited  as  ever. 

As  might  be  expected,  headache  is  sometimes  complained 
of,  but  usually  in  lucid  pauses,  or  when  convalescence  is 
coming  on.  It  may  be  in  the  frontal  region  or  elsewhere, 
often  on  the  top  of  the  head.  I  have  noticed  occasionally 
that  lactation  patients  are  liable  to  suffer  from  bronchial 
catarrh  and  from  rheumatic  pains,  with  tenderness  on 
pressure,  especially  over  the  joints,  which  in  some  instances 
are  red  and  swollen.  It  has  struck  me  as  interesting  that 
rheumatic  affections  should  be  associated  with  excessive 
lactation,  and  an  examination  of  the  skin  in  a  few  of  my 
patients  revealed  a  profuse  acid  perspiration,  which  changed 
blue  litmus  to  a  red  colour.  Further,  we  have  observed  that 
salicylate  of  soda  or  other  alkaline  treatment  gave  relief  in 
many  cases.  One  of  my  patients  had  rheumatic  fever 
previous  to  lactation.  Savage  mentions  rheumatism  in  one 
of  the  two  cases  recorded  in  his  book,  but  many  are  so  slightly 
affected  as  almost  to  pass  unnoticed,  and  considering  that 
the  lactic  acid  theory  of  the  blood  condition  in  rheumatism 
has  not  3^et  received  its  quietus,  these  cases  are  interesting. 
That  there  is  a  specially  susceptible  constitution  at  such 
times  is  very  probably  true,  and  the  conditions  favourable  for 
rheumatism  to  prey  on  them  are  present  in  many  cases  where 
the  mother  is  not  in  affluent  circumstances. 

Anaemia  is,  however,  the  constitutional  state  which  calls 
for  most  attention,  and  it  is  the  morbid  condition  which 
explains  many  of  the  sensory  and  other  phenomena  of  this 
disease.  The  pallor  of  these  cases  and  the  emaciated,  im- 
poverished state  are  striking,  and  haimic  murmurs  are  almost 
invariably  constant  in  those  instances  where  prolonged  lacta- 
tion has  been  the  rule. 

Features  special  to  Melancholia. — There  is,  of  course,  mental 


PUERPERAL  AND  ALLIED  INSANITIES  345 

depression,  often  great  excitement  and  intense  fear  and 
anxiety.  The  delusions  and  their  persistence  are  very 
suggestive  of  the  persecution  stage  of  chronic  progressive 
delusional  insanity.  They  give  evidence  ad  libitum  of  the 
morbid  trend  of  the  patient's  thoughts.  She  is  thinking 
about  herself,  and  often  about  her  baby.  They  are  the 
sufferers,  and  others  are  the  persecutors.  One  patient's 
delusions  were  that  her  sister  had  destroyed  her  child,  and 
that  other  people  had  put  dirt  in  her  skin.  A  second  said 
that  she  was  '  dissected  and  confugled  by  a  set  of  maidens,' 
while  a  third  refused  food  under  the  delusion  that  it  was 
poisoned.  Some  cases  are  quiet,  and  moan  and  groan  in  a 
subdued  way  to  themselves  ;  but  the  tendency  to  paroxysmal 
outbreaks,  and  to  suicide  or  homicide,  must  always  be  kept  in 
mind,  even  with  apparently  quiet  cases. 

Features  special  to  Mania. — These  are  much  more  charac- 
teristic, and  just  as  melancholia  suggests  one  stage — obsession 
of  persecution  —  in  chronic  progressive  insanity,  mania 
suggests  a  subsequent  stage — megalomania,  the  grandiose 
stage.  Delusions  of  identity  are  common,  and  the  doctors 
are  usually  exalted  on  a  high  pedestal  by  deluded  lacto- 
maniacs,  themselves  occupying  an  equally  exalted  pedestal 
near  him.  In  one  instance  the  delusions  were  that  the 
doctor  was  the  Marquis  of  Lome,  and  the  patient  Lady 
Hastings,  his  fiancee.  Another  declares  herself  a  Duchess, 
denies  that  she  has  a  husband  or  children,  and  makes 
affectedly  shy  overtures  to  the  doctor,  whom  she  believes  to 
be  a  Prince.  This  lady  is  very  unsociable,  haughty,  dis- 
dainful, and  her  hauteur  of  manner  is  magnificent.  She  is 
handsome,  her  carriage  is  naturally  dignified,  and  a  vain 
conceit  runs  through  all  her  actions. 

These  patients  entertain  strong  dislikes  of  particular  in- 
dividuals, their  friends  and  the  nurses  in  attendance,  and  the 
striking  fact  about  these  dislikes  is  that  they  are  usually 
insane  prejudices  of  the  most  intolerant  description,  and 
that  they  are  nursed  from  day  to  day,  and  give  rein  to  very 
violent  and  malignant  attacks  upon  their  victims.  Lacto- 
maniacs  are  impatient  of  control ;  their  exalted  delusions  are 
not  without  a  backbone  of  character  behind  them,  being  in 


346  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

this  respect  very  different  from  the  chimerical  morbid  fancies 
of  some  other  insane  people.  In  their  own  estimation  they 
are  persons  of  importance,  and  they  command  submission 
from  those  'around  them.  Hence  they  fight  against  the 
discipline  of  the  sick-room  or  hospital  ward,  and  refuse  to 
be  coaxed  or  coerced  into  any  line  of  conduct  that  does  not 
fall  in  with  their  own  conception  of  the  fitness  of  things. 
They  often  affect  a  shyness  in  the  presence  of  the  male  sex. 
One  other  characteristic  of  some  of  these  maniacal  cases 
is  that  they  may  combine  exaltation  at  one  period  with  the 
most  reckless,  obscure,  and  degraded  conduct  at  another. 
As  a  rule,  however,  the  maniacal  type  takes  one  or  other 
form..  In  this  latter  condition  all  sense  of  decency  is  thrown 
to  the  winds,  the  patient  breaks  out  in  reckless  abandon,  lies 
down  and  kicks,  is  very  indecent  in  manner  and  conduct,  and 
obscene  in  speech.  She  may  be  wickedly  mischievous  and 
destructive,  and  her  freaks  of  mad  impulse  often  end  in  the 
wreckage  of  everything  around  her. 

Prognosis. 
The  prognosis  of  insanity  of  lactation  is  good.  Clouston's 
recovery  rate  is  77*5  per  cent.,  and  I  should  judge  from  my 
experience  that  this  is  near  the  average  results  obtained. 
Elsewhere  it  is  said  by  some  that  recovery  takes  place  early, 
but  my  experience  does  not  bear  this  out  both  as  regards 
maniacal  and  melancholic  cases.  One  of  the  latter  was 
insane  two  years.  One  thing  is  certain,  that  in  not  a  few 
cases  aversion  to  the  husband  is  entertained  for  a  long  time. 
Many  are  so  much  run  down  that  the  building-up  process,  the 
restoration  of  the  blood  and  bodily  condition  to  par,  is  a  ques- 
tion of  a  long  time  ;  but  the  prognosis  in  general  is  very  favour- 
able. The  death  rate  is  lower  for  lactation  cases  than  it  is  for 
the  puerperals. 

Treatment. 

It  need  scarcely  be  said  that  blood  tonics  are  of  the  first 
importance.  Iron  may  be  prescribed  in  the  form  that  seems 
to  the  doctor  in  attendance  most  indicated.  The  syrup  of 
the  Hydrobromates  of  Quinine  and  Iron  (Fletcher's),  with  or 
without  Liq.  Arsen.  Hydrochlor.,  is  a  very  useful  preparation, 


PUERPERAL  AND  ALLIED  INSANITIES  347 

and  seems  to  have  a  specially  tonic  and  sedative  influence.  The 
refusal  of  food  may  be  as  much  due  to  atonic  dyspepsia  as  to 
delusions,  and  it  may  be  necessary  to  prescribe  digestive  stimu- 
lants and  other  aids  in  such  cases.  In  many  of  our  patients 
porter  is  well  borne,  and  has  a  sedative  as  well  as  nutritive 
effect  ;  but,  as  a  rule,  alcohol  in  any  other  form  during  the 
acute  stage  of  the  disease  is  contra-indicated  unless  a  typhoid 
state  supervenes.  In  anaemic  states  generally,  the  tendency 
is  to  constipation,  and  in  these  patients  anaemia  is  a  common 
complaint.  It  is  well,  therefore,  to  have  strict  attention  paid 
to  the  alvine  evacuations.  Such  patients  may  require  hospital 
treatment,  and  have  to  be  kept  in  bed,  especially  if  the  breasts 
are  troublesome;  but,  as  a  rule,  it  is  found  possible  to  exercise 
them  a  great  deal  in  the  open  air  with  less  restraint  than 
if  they  were  confined  within  four  walls  all  the  time.  This 
assists  Nature's  recuperative  efforts  and  the  tonic  treatment 
of  the  case,  and  is  therefore  much  more  likely  to  procure  sleep. 
Discipline  in  the  maniacal  cases  is  difficult  to  attain,  and 
here  great  tact  is  called  for.  If  such  cases  can  be  induced 
to  engage  in  active  employment,  something  that  makes  a 
real  call  on  the  muscular  energies,  a  great  advance  is  made 
in  the  treatment  of  the  patient,  the  paroxysms  of  excitement 
are  kept  well  under  control,  and  more  sleep  is  obtained.  In 
the  treatment  of  melancholic  cases,  it  need  scarcely  be  repeated 
that  active  occupation  is  of  no  less  importance.  It  is  the 
only  thing  tu  keep  them  from  brooding  over  their  fancied 
wrongs. 

Clinical    Illustrations. 

insanity  of  pregnancy. 

J.  Pregnancy,   Second  Month;    Suicidal  Impulse;    Fracture  of 
Pelvis  ;  A  hortion  ;  Recovery. 

Mrs.  T.  B.  was  a  young  woman,  aged  21,  whose  insanity 
appeared  suddenly,  and  who  leaped  from  a  four-story  window 
while  in  a  state  of  frenzy.  On  admission  to  the  infirmary 
she  was  found  to  have  sustained  a  fracture  of  the  pelvis  and 
a  lacerated  wound  on  the  forehead.  No  other  fracture  was 
detected.     There  was    some    discharge    of  blood    from    the 


348  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

vagina.  On  passing  a  catheter  into  the  bladder,  a  quantity  of 
bloody  urine  was  drawn  ojff;  the  catheter  also  was  found  to 
impinge  on  loose  bone.  Eight  hours  afterwards  she  aborted, 
apparently  in  the  second  month.  During  the  night  she  was 
very  restless,  and  annoyed  the  patients  so  much  that  she 
had  to  be  sent  to  the  asylum.  On  admission  to  the  asylum 
her  mental  condition  was  as  follows :  She  talked  in  a  con- 
fused, rambling  way,  said  she  had  a  vision  the  previous 
night,  when  wide  awake,  of  a  woman  and  child  beside  her. 
She  was  very  unhappy,  and  could  not  throw  off  the  feeling. 
She  had  no  recollection  of  coming  to  the  infirmary,  and 
could  not  realize  why  she  was  there  at  all.  She  refused 
food,  and  had  to  be  fed  artificially.  As  she  recovered  from 
her  injuries  and  gained  strength,  her  mind  improved,  and 
she  recovered ;  but  very  little  explanation  of  her  suicidal 
attempt  could  be  obtained,  beyond  a  vague  recollection,  like 
a  horrible  dream,  probably  a  hallucination  of  sight. 

//.  Unhappy  Marriage  made  against  the  wishes  of  friends,  with  a 
man  who  was  found  to  have  married  under  an  assumed  name, 
and  to  be  a  deserter  from  the  army ;  Melancholia,  Suspicion, 
Irritability,  Impulsiveness,  Recovery. 

Mrs.  J.  B.  C,  aged  20,  insane  six  days  on  admission  ;  first 
pregnancy,  fifth  month.  This  woman  was  anaemic  and  pale ; 
she  had  an  unhappy,  miserable,  ill-natured  expression,  was 
most  taciturn,  could  not  be  got  to  engage  in  conversation. 
She  was  unsociable  and  exceedingly  disagreeable.  She  was 
evidently  labouring  under  severe  depression,  and  there  was 
evidence  of  morbid  resentment  of  anything  said  or  done  for 
her.  She  was  subject  to  several  hallucinations  and  delusions  ; 
she  was  in  the  habit  of  spitting  a  good  deal  on  the  floor  because 
of  a  bad  taste  in  her  mouth,  which  she  said  was  due  to  poison. 
She  had  the  hallucination  that  she  heard  her  husband's  voice 
on  the  other  side  of  the  door.  She  was  under  the  delusion 
that  people  were  outside,  and  evidently  was  suspicious  as  to 
their  purpose.  Certain  articles  of  diet  she  would  not  touch, 
such  as  bread,  believing  it  to  be  poisoned.  She  refused  food 
so  deliberately  that  she  had  to  be  fed  artificially.  She  was 
under  some  delusion  regarding  the  doctor.     At  a  later  date 


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PUERPERAL  AND  ALLIED  INSANITIES  349 

the  explanation  was  that  she  beheved  him  to  have  been  her 
enemy  from  the  first,  and  that  he,  instead  of  trying  to  cure 
her  of  brain-fever,  was  making  her  worse.  The  only  history 
obtained  at  the  outset  was  that  of  her  marriage,  against  the 
wishes  of  her  friends,  with  a  stranger  who  had  come  to 
the  neighbourhood,  and  of  whom  she  knew  nothing.  Her 
husband  came  to  see  her,  and  seemed  of  a  low  type.  It  turned 
out  later  that  he  had  been  a  deserter,  and  had  married  her 
under  an  assumed  name.  The  fact  of  this  discovery,  com- 
bined with  the  reproaches  of  her  friends,  upset  her  so  much 
that  she  became  insane.  For  several  months  she  remained 
in  the  asylum  ;  but  before  the  birth  of  her  child  she  quite 
recovered,  though  she  still  was  rather  depressed  on  account 
of  her  unfortunate  marriage. 

PUERPERAL    INSANITY. 

///.  Melancholia  :  Midtipara,  Religious  Delusions  of  Depressing 
Character ;  Acute  Phthisis,  Death. 

Mrs.  H.  C.  This  was  the  case  of  a  refined,  intelligent  lady 
of  distinctly  nervous  diathesis,  of  a  naturally  religious  disposi- 
tion, who  was  exceedingly  sensitive,  and  had  been  depressed 
for  several  months  owing  to  the  death  of  a  favourite  child. 
Her  child-bearing  history  had  no  unfavourable  incidents. 
As  to  her  present  illness,  the  first  thing  noticed  was  that  she 
made  disparaging  remarks  about  her  husband  after  the  birth 
of  her  last  child.  A  few  days  later  she  turned  against  the 
child  itself,  and  still  later  took  a  dislike  to  all  her  children. 
Sleeping-draughts  were  of  no  avail.  She  had  suffered  for 
some  rnonths  from  a  trouble  in  her  throat,  ascribed  by  the 
doctor  to  ulceration  of  the  vocal  cords.  On  admission  the 
following  observations  were  made  :  The  patient  was  of 
average  size,  but  reduced  in  condition,  of  dark  complexion, 
weighed  8  stones  ;  the  temperature  was  104°.  Mentally  there 
was  considerable  activity,  especially  on  religious  subjects,  and 
an  expression  of  anxiety  was  depicted  on  her  countenance. 
Her  ideas,  to  which  she  freely  gave  expression,  showed  that 
the  bent  of  her  thoughts  was  in  a  melancholic  direction. 
Her  whole  mind   seemed   absorbed  with  two  great   ideas — 


350  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

the  prospect  of  her  near  demise,  and  the  relation  in  which 
she  stood  to  her  Maker.  The  attention  was  easily  iixed, 
and  she  was  evidently  a  person  of  superior  intelligence ;  the 
features  were  delicately  chiselled,  regular,  and  refined;  the 
eyes  bright  and  black,  and  the  whole  appearance  that  of  a 
highly  nervous  temperament  combined  with  a  tubercular 
diathesis. 

The  pulse  was  132,  small  and  weak,  the  heart-sounds 
apparently  normal,  but  the  action  was  too  rapid  for  accurate 
auscultation.  Respiration  30,  shallow  and  not  distressing ; 
frequent  loose  cough  with  muco-purulent  sputum  ;  harsh  and 
sonorous  rales  heard  over  the  chest,  but  especially  over  the 
right  side  ;  the  very  slightest  impairment  of  percussion  could 
be  detected  there.  The  lochial  discharge  was  profuse, 
greenish,  and  very  offensive  ;  the  urine  was  abundant  and 
slightly  albuminous.  The  mental  symptoms  subsided  some- 
what, but  now  and  again  she  had  periods  of  excitement 
in  which  she  cried  out,  wringing  her  Jiands  and  looking 
frightened,  that  she  was  lost,  that  the  devil  was  hunting  her, 
and  that  she  could  see  him.  It  was  a  curious  fact  that,  in 
spite  of  this  depression,  in  spite  of  the  conclusion  that  was 
forced  upon  us  that  her  whole  being  was  shaken  over  the 
religious  question  of  her  salvation,  and  her  great  mental 
anxiety,  one  worldly  passion  still  remained,  shown  in  her 
perverted,  suspicious  nature,  for  she  could  not  bear  for  a 
moment  that  a  word  should  pass  between  her  husband  and 
the  nurse,  of  whom  she  was  intensely  jealous  when  the  hus- 
band was  present.  Her  illness  proceeded  rapidly  to  a  fatal 
close ;  and  death  ensued  at  the  end  of  the  fourth  week. 

IV.  Acute  Delirious  Mania:  Priniipara ;  Illegitimacy ;  Acute 
Phthisis,  Death. 

A.  F.  C.  This  was  the  case  of  a  young  woman,  aged  26, 
a  weaver,  unmarried,  who  had  been  very  careless  about  her 
health  during  pregnancy,  perhaps  from  mental  causes,  and  had 
suffered  from  cough  during  the  previous  winter.  Her  labour 
was  natural,  but  the  milk  was  suppressed,  and  the  lochial 
discharge  had  an  extremely  offensive  odour.  The  first  mental 
change  was  observed  within  twenty-four  hours  after  the  child's 


PUERPERAL  AND  ALLIED  INSANITIES  351 

birth.  She  took  httle  notice  of  her  baby,  did  not  appear 
to  recognise  it  as  hers,  and  evidently  the  maternal  instinct 
was  wanting.  On  admission  she  presented  a  tall,  dark 
and  swarthy  appearance,  with  bright  black  eyes,  and  was 
extremely  wild  and  delirious.  In  her  delirium  she  repeated 
herself,  phrase  after  phrase  the  same,  and  there  was  a 
sarcastic  tone  running  through  it  all.  She  would  talk  non- 
sensically and  irrelevantly  in  answer  to  questions  ;  her  delu- 
sions were  numerous  and  fleeting,  but  they  were  evidently 
exalted  in  character.  The  pulse  was  144  and  small,  and 
it  was  observed  that  there  was  moderate  dulness  on 
percussion  at  the  left  apex,  and  the  heart-sounds  were  pro- 
pagated clearly  to  this  spot.  Her  nights  and  days  were 
characterized  by  one  continuous  state  of  restless,  noisy, 
delirious  excitement.  She  was  persistently  endeavouring  to 
get  out  of  bed,  tossing  the  bedclothes,  indecent  in  manner 
and  conversation,  and  all  the  time  talking  and  raving  inco- 
herently. She  suffered  from  diarrhoea;  the  stools  were  foetid; 
the  vaginal  examination  later  revealed  no  sign  of  tenderness, 
but  pressure  over  the  uterus  gave  indication  of  pain.  The 
appetite  was  capricious.  She  was  extremely  thirsty,  and, 
like  many  puerperals,  would  drink  large  quantities  of  butter- 
milk. She  had  hallucinations  of  sight,  smell,  and  hearing. 
She  saw  and  heard  her  father,  etc.,  and  she  seemed  to  see 
imaginary  things,  e.g.,  silver  floating  in  the  air;  she  said  she 
could  smell  chloroform,  vitriol,  and  sulphur  on  the  bed- 
clothes. She  died  three  weeks  after  admission,  and  post- 
mortem examination  confirmed  the  diagnosis  of  phthisis. 

V.  Actde  Mania  :  Multipara;  Septiccemia,  Pelvic  Celhditis, 

Recovery. 

Mrs.  Q.  P.  This  case,  though  also  a  very  severe  one, 
after  much  work  and  anxiety  was  pulled  through.  Her  age 
was  twenty-six ;  she  had  been  insane  two  weeks  before 
admission  ;  she  had  had  seven  children  ;  all  the  labours  were 
natural  until  the  last,  when  she  had  twins,  and  was  at  first 
attended  by  a  midwife,  who  introduced  her  hand  into  the 
uterus.  One  of  the  twins  was  stillborn,  and  the  patient 
was  partially  unconscious  during  the  latter  part  of  labour. 


352  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

There  was  a  good  deal  of  haemorrhage  ;  the  lochial  discharge 
stopped  on  the  seventh  day.  Milk  was  plentiful  all  the 
time.  The  patient  was  sleepless  from  the  first  after-labour, 
and  got  sleeping-draughts.  She  gradually  became  excited, 
singing  and  crying  by  turns,  and  was  very  unmanageable  ; 
she  suffered  from  pelvic  inflammation  after  the  birth  of  the 
children. 

On  admission  she  was  bright  and  lively,  extremely  pale 
and  anaemic.  Mentally  there  was  considerable  exaltation,  as 
evidenced  by  her  bright,  animated  expression,  her  happy, 
boisterous,  devil-may-care  manner,  and  the  nature  of  the 
delusions.  She  was  extremely  excited,  but  her  incoherence 
was  not  so  extreme  as  in  the  previous  case.  Her  memory 
could  not  be  tested  by  interrogation  owing  to  her  excite- 
ment and  waywardness,  but,  judging  from  her  spontaneous 
speech,  it  seemed  acute.  The  delusions  were  numerous,  and 
usually  fleeting.  There  was  a  rise  and  fall  in  her  mental  excite- 
ment, sudden  outbursts  which  just  as  suddenly  subsided.  It 
was  mischievous,  wayward,  childish  and  purposeless.  In 
a  moment,  if  the  nurse's  back  was  turned,  she  was  out  of 
bed,  and  either  overturning  everything  in  the  room,  destroy- 
ing articles,  or  breaking  glass.  One  good  thing  about  this 
patient  was  that,  in  spite  of  her  excitement,  she  slept  well 
and  took  her  food  well. 

A  septicaemic  abscess  broke  out  in  the  right  thigh  five 
days  after  admission.  It  was  freely  incised,  and  discharged 
a  thick,  creamy  pus.  Three  days  later  an  abscess  formed 
in  the  right  axilla,  the  size  of  an  orange.  At  this  time 
she  vomited  everything  she  took ;  the  urine  was  dark, 
almost  black ;  the  stools  were  clay-coloured  ;  there  was  no 
albumen  in  the  urine,  but  bile  pigment  was  present.  A  few 
days  later  the  abscess  in  the  axilla  was  opened,  and  later  one 
over  the  left  elbow-joint.  Finally  appeared  pelvic  cellulitis, 
ending  in  an  abscess  pointing  towards  the  pubes,  a  little  to 
the  left  side.  At  this  stage  she  became  much  exhausted,  and 
her  condition  was  very  critical.  The  abscess  was  treated  by 
suprapubic  incision,  with  antiseptic  precautions,  and  ulti- 
mately the  wound  closed ;  but  she  was  in  a  very  reduced, 
extremely  anaemic   state.     In  this  case  enemata  of  defibri- 


PUERPERAL  AND  ALLIED  INSANITIES  353 

nated  blood  were  used  with  apparent  success.  Thereafter 
she  made  rapid  progress,  and  recovered  mentally  and  physi- 
cally. 

VI.  Mania  :  History  of  Epileptic  Seizures,  Metritis,  Obscene 
CondiLct,  Exposing  herself,  Ojfensive  and  Indecent  Lan- 
guage ;  Recovery. 

Mrs.  F.  B.  This  was  the  case  of  a  young  woman,  aged 
21,  in  poor  circumstances,  of  a  somewhat  hysterical 
character,  in  whom  insanity  only  lasted  for  a  few  weeks. 
The  labour  was  rather  a  long  and  tedious  one,  lasting  forty- 
eight  hours.  During  the  second  stage,  though  it  was  fairly 
rapid,  she  was  extremely  excitable,  tossing  about  incessantly 
and  screaming.  Chloroform  had  to  be  given  before  delivery 
could  be  accomplished.  She  had  two  abortions  previously. 
The  first  mental  symptoms  were  restlessness,  irritability,  and 
a  positive  determination  to  be  out  of  bed  and  sitting  up. 
This  was  noticed  on  the  second  day  after  delivery.  The 
first  bodily  symptom  observed  was  the  disappearance  of  the 
lochia.  On  the  second  day  there  was  inability  to  micturate. 
She  complained  of  pains  in  the  hypogastric  region.  The 
temperature  was  i03'5°  on  the  third  day  after  delivery,  and 
then  gradually  subsided.  She  was  always  cold  and  shivering 
after  labour  up  to  the  time  of  the  mental  attack.  From  the 
day  the  baby  was  born  she  could  not  sleep,  and  she  lost  her 
hearing  before  the  birth  of  the  child.  She  got  some  wine 
on  the  fourth  day,  and  very  likely  this  upset  her  more  than 
ever.  She  had  two  or  three  epileptic  seizures,  and  after  that 
became  more  and  more  unmanageable,  more  violent  and  un- 
controllable. 

On  admission  to  the  asylum  she  was  very  incoherent ;  her 
conduct  was  violent  and  obscene.  She  attempted  to  injure 
those  around  her,  and  exposed  her  person  to  warm  herself 
at  the  fire.  She  was  continually  screaming,  resisting,  and 
calhng  out,  'The  Blessed  Virgin  Mary!'  The  attack  was 
distinctly  hysterical  in  character,  and  passed  off  very  soon. 
She  was  much  improved  by  attention  to  the  bowels  and 
uterus.  She  had  tepid  baths  at  night,  and  was  poulticed. 
She  had  a  keen  feeling   of  depression  when   she   came   to 

23 


354  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

herself,  and  then  settled  down  into  a  quiet,  useful  woman. 
Her  recovery  took  place  in  a  fortnight. 

Here  may  be  noticed  what  is  quite  common  in  these 
cases,  the  mercurial  relation  of  the  mental  to  the  bodily 
state.  Any  uterine  disturbance,  the  retention  of  a  clot,  for 
example,  constipation,  retention  of  urine,  are  sure  to  increase 
the  mental  excitement,  and  it  falls  with  the  relief  of  these 
conditions.  In  one  patient  there  followed  three  mental 
crises  on  the  formation  and  retention  of  clots  in  the  uterus, 
three  crises  of  intense  hysterical  excitement  with  hyper- 
pyrexia ;  but  they  subsided  on  the  discharge  of  the  clots. 

VII.  A  cute  Mania  :  Primipara  ;  Second  A  ttack,  Reduced  Bodily 
Condition  ;  Recovery. 

Mrs.  G.  B.,  aet.  22,  primipara ;  admitted  for  her  second 
attack.  She  had  been  insane  before  marriage,  but  no 
hereditary  history  of  insanity  or  nervous  disease  could  be 
obtained.  During  pregnancy  she  had  suffered  from  dis- 
order of  the  stomach,  and  at  that  time  she  was  dull  and 
low-spirited,  her  husband  being  out  of  employment.  She 
became  insane  in  the  first  fortnight  after  childbirth.  The 
lochial  discharge  was  scanty,  the  milk  suppressed,  and  the 
breasts  very  tender.  On  admission  her  temperature  was  98*6°. 
She  showed  considerable  exaltation,  had  a  happy  expression, 
sang,  laughed  and  danced  with  great  gusto.  Frequent 
questioning  elicited  only  occasional  replies,  and  these 
mechanical,  often  irrelevant  and  abrupt.  There  was  much 
incoherence,  and  her  delusions  were  numerous,  and  of  exalted 
type.  For  example,  she  called  herself  an  actress,  the 
daughter  of  the  regiment,  etc. 

After  admission  she  was  most  noisy  at  times,  very  de- 
structive, tearing  her  clothing  and  bedclothes,  throwing 
things  into  the  fire,  etc.  She  sang  a  great  many  songs,  and 
danced  often  without  intermission  for  a  long  time  in  imita- 
tion of  ballet-girls.  If  forced  to  sit  down,  she  would  cry  like 
an  angry  child  for  a  few  moments,  but  her  irrepressible 
sense  of  well-being  quickly  reasserted  itself,  and  she  re- 
gained her  gaiety  of  disposition,  and  indulged  again  in 
antics  and  mischief  with  unabated  vigour.     She  constantly 


PUERPERAL  AND  ALLIED  INSANITIES  355 

tried  to  undress  herself,  and  delighted  in  a  semi-nude  condi- 
tion. She  was  very  noisy  at  night,  sometimes  for  four  or 
five  nights  consecutively.  For  a  time  she  was  dirty  in  her 
habits,  used  very  foul  language,  and  on  several  occasions 
struck  both  patients  and  nurses.  Three  months  after 
admission  she  menstruated  ;  then  she  became  quieter  and 
more  coherent,  put  on  flesh,  and  recovered  a  few  months 
later,  having  gained  in  weight  39  pounds. 

VIII.  First  A  ttack  was  one  of  Post-Connubial  Insanity  ;  Second 
Attack,  Puerperal  Insanity;  Third  Attack,  Puerperal  Insanity. 

Mrs.  C.  B.,  set.  23.  The  history  shows  that  a  mental 
change  was  coming  over  her  before  marriage.  She  objected 
to  the  caresses  of  her  intended  husband ;  she  exclaimed  to 
her  mother,  '  I  used  to  be  full  of  plans,  but  I  have  no  interest 
in  plans  any  more.'  She  went  off  her  sleep  some  weeks 
before  marriage  ;  the  night  of  marriage  would  not  allow  her 
husband  near  her ;  she  menstruated  next  day.  Then  she 
became  excited,  frightened,  and  subject  to  hallucinations 
and  delusions.  She  cried  to  her  people,  '  Keep  back,  or  you'll 
be  burnt — this  is  the  last  day ' ;  '  Don't  you  hear  the  sticks 
cracking,  hell's  fire?'  Later  she  became  maniacal,  was 
vicious  and  kicked,  ate  ravenously,  and  was  extremely 
thirsty.  She  had  delusions  of  identity ;  she  recovered  in 
seven  months. 

First  Puerperal  Attack. — She  got  a  fright  because  her  baby 
was  born  quickly,  and  before  the  doctor  could  arrive.  Her 
insanity  in  some  respects  resembled  the  previous  attack,  but 
in  addition  were  grafted  the  delusions  more  characteristic  of 
puerperal  insanity.  She  believed  herself  to  be  the  wife  of 
Jesus  Christ  and  the  sister  of  John  the  Baptist,  whom  she 
recognised  in  the  asylum  gardener.  She  believed  that  one 
of  the  nurses  was  the  mother  of  Christ,  and  hated  her 
accordingly.  She  was  free  from  genito-urinary  trouble  of 
any  kind,  but  was  very  anaemic.  Her  insanity  was  of  a  more 
playful  character  than  on  the  previous  occasion,  and  dis- 
tinctly puerile. 

She  was  outrageous,  childish  and  spiteful,  kicked,  bit  and 
threw  things  about ;   her  conduct  was  erotic  and  obscene, 

23—2 


356  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

and  distinctly  suggestive  of  sexual  excitement — mock' kissing, 
talking  of  true  love,  and  of  lying  in  bed,  etc.  She  indulged 
freely  in  mimicry.  She  said  she  had  a  carbuncle  in  her 
back,  and  walked  nearly  double  as  if  imitating  someone. 
She  would  slap,  bite,  or  spit,  if  anyone  remonstrated  with 
her,  and  was  knowingly  mischievous,  and  all  the  worse  the 
more  she  was  taken  notice  of.  She  pretended  she  was  a 
sparrow,  and  chirruped  ;  would  put  out  her  tongue  and  grip 
it,  swinging  it  to  and  fro  in  imitation  of  a  bell ;  she  blew 
with  her  mouth  in  imitation  of  a  horn,  and  pawed  and 
scratched  like  a  cat.  Her  recovery  came  after  many  transient 
lucid  intervals  and  relapses,  which  made  her  case  appear 
almost  hopeless.  She  became  insane  again  after  the  birth 
of  her  second  child,  and  her  attack  presented  a  strong  famil}- 
likeness  to  the  one  just  described. 

INSANITY    OF    LACTATION. 

7A'.  Melancholia  witJi  Abscess  of  Mamma  ;  Recovery. 

Mrs.  H.  K.,  set.  41,  was  admitted  with  the  following 
history  :  She  had  eight  children,  the  youngest  about  ten 
months  old,  which  had  been  suckled  up  to  within  three  or 
four  days  of  admission  ;  her  breasts  were  troublesome  and 
sore  for  about  five  or  six  weeks  before  admission.  She  had 
suckled  all  her  children,  and  usually  till  they  were  about 
eighteen  months  of  age.  Her  condition  was  one  of  intense 
melancholia  with  great  restlessness,  delusions,  and  halluci- 
nations. She  believed  that  all  her  friends  and  her  husband 
had  forsaken  her,  and  her  excitement  took  a  violent  form,  in 
which  she  tried  to  destroy  herself.  It  was  with  the  greatest 
difficulty  she  could  be  restrained  from  injuring  herself.  She 
had  the  hallucination  that  she  saw  figures  moving  about  her 
bed,  and  that  she  heard  voices  and  objects  whispering  in  her 
ears.  She  attacked  her  husband  and  her  sister.  In  the 
asylum  she  had  the  delusion  that  the  medical  officer  was  a 
very  old  friend  of  hers,  although  he  had  never  seen  her  prior 
to  her  admission.  Abscess  of  the  breast  was  the  exciting 
cause  in  this  case.  It  discharged  freely,  and  under  good 
regimen  and  surgical  treatment  she  made  a  quick  recovery, 
being  only  in  the  as^dum  two  months. 


PUERPERAL  AND  ALLIED  INSANITIES  357 

X.  Resistive  Melancholia  with  Stuporose  State;  Refusal  of  Food ; 

Extremely  Anceniic. 

Mrs.  K.  G.  This  was  a  little  thin,  flaccid,  angemic  woman, 
whose  face  wore  a  constant  crying  expression,  who  would 
sometimes,  though  rarely,  speak  in  reply  to  questions,  and 
call  out  '  The  priest,  the  priest !'  or  '  Heaven,  heaven  !'  She 
was  in  a  state  of  melancholy,  and  would  not  do  anything  that 
she  was  asked.  If  she  was  put  one  way,  she  would  pull  the 
other ;  if  she  was  made  to  sit  down  in  a  chair,  she  would 
stand  up  ;  if  she  was  made  to  stand,  she  would  sit  down. 
She  could  not  be  persuaded  to  take  her  food  for  some  time 
after  admission,  instead  of  this  calling  for  the  priest  and 
talking  of  heaven.  She  had  complained  of  pains  in  the  head 
for  some  time  before  the  attack  ;  the  pulse  was  115,  and  there 
were  hsemic  murmurs  {hruit  de  diahle)  at  the  root  of  the  neck  ; 
the  tongue  was  coated  with  a  white  fur  ;  the  pupils  were 
dilated ;  consensual  reflex  impaired ;  corpuscular  richness 
of  the  blood  was  4,500,000  ;  percentage  of  haemoglobin  48. 
Although  seemingly  dazed  and  stuporose,  this  woman  had 
attacks  of  excitement  and  great  restlessness,  evidently  in  a 
state  of  intense  melancholic  distress,  so  that  she  could  not 
be  kept  in  bed,  but  was  always  getting  up  and  getting  out. 
She  was  transferred  to  another  asylum. 

XI.  Unhappy   Married   Life;    Drunken,   Dissolute   Husband; 

Melancholia ;  Recovery. 

Mrs.  C.  R.,  who  had  a  drunken,  disreputable  husband, 
had  married  against  the  family  wishes ;  and  her  husband 
turned  out  a  drunken  reprobate  and  hypocrite,  became 
insane,  and  was  treated  in  the  asylum.  He  had  led  her  a 
wild  dance,  and  while  he  was  in  the  asylum  she  gave  birth 
to  a  child,  which  she  nursed  under  these  very  unfavourable 
domestic  circumstances.  She  became  insane,  turned  against 
her  husband,  to  whom  she  had  been  most  devoted  in  spite 
of  his  character,  threatened  to  kill  her  child  and  her  husband, 
and  attempted  suicide.  On  coming  into  the  asylum,  she  was 
in  a  semi-hysterical  state,  crying  out,  invoking  the  help  of 
the  Almighty,  assuming  for  long  periods  penitential  attitudes, 


358  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

etc.  She  was  exceedingly  distressed  owing  to  the  breaking 
off  of  all  relations  with  her  family.  This  preyed  very  much 
on  her  mind,  and  she  indulged  frequently  in  long  fits  of 
sobbing  over  the  matter.  She  was  extremely  anaemic ; 
pulse  io8 ;  breasts  full,  firm,  and  tender.  She  feared 
abscess,  as  she  had  been  so  affected  before  ;  the  pupils  were 
dilated,  the  left  more  so  than  the  right,  and  not  so  responsive 
to  light.  After  a  time  the  penitential  attitudes  and  hysterical 
fits  of  sobbing  ceased ;  she  made  herself  useful,  and  was  an 
exceedingly  clever  woman  in  the  wards.  When  recovered, 
she  was  sent  out  and  away  from  her  husband,  after  she  had 
been  insane  for  over  six  months. 

XII.   Mania  :  Exalted  Delusions,  Furious  Impulses,  Strong 
Dislikes;  Recovery. 

Mrs.  W.  A.,  a;t.  39,  was  admitted  to  the  asylum  in  a  state 
of  furious  ravnig  incoherence,  with  delusions  of  exalted 
character.  She  recognised  the  medical  officer  as  a  titled 
gentleman,  fell  in  love  with  him,  declared  she  also  was  a 
titled  lady,  and  that  she  was  about  to  be  married  to  him. 
Her  attacks  seemed  often  to  be  excited  by  friction  with  the 
nurses  over  questions  of  discipline.  She  would  not  be  ordered 
about ;  she  declined  to  receive  any  instructions,  and  it  vexed 
her  soul  exceedingly  that  she  could  not  come  and  go  as  she 
pleased.  The  result  was  that  she  became  often  very  violent. 
Her  feelings  were  most  mobile  ;  in  a  moment  she  could  be 
moved  into  a  paroxysm  of  rage  and  fury  in  which  she  was 
completely  carried  beyond  herself.  She  took  strong  dislikes, 
and  these  dislikes  remained  for  weeks  and  months  until  she 
became  convalescent.  She  was  exceedingly  angry  at  the 
mention  of  her  husband's  name.  She  declared  she  had  no 
husband  and  no  children,  that  she  was  an  unmarried  woman, 
and  the  very  suggestion  that  she  was  otherwise  was  enough 
to  make  her  furious.  The  breath  was  exceedingly  offensive, 
the  lips  dry.  She  refused  food.  Moist  rales  were  clearly 
audible  over  the  chest.  She  was  ansemic,  and  the  bruit  de 
diable  was  loud  and  diffuse  at  the  root  of  the  neck.  The 
temperature  on  admission  was  99°.  She  was  insane  two 
3-ears  before  she  recovered. 


PUERPERAL  AND  ALLIED  INSANITIES  359 

XIII.  Mania  :  Husband  killed  Eighteen  Months  before  ;  Nursed 
Baby  close  on  Fifteen  Months ;  went  to  a  Situation,  and  then 
became  Insane  ;  Rheumatic  Symptoms  :  Recovery. 

Mrs.  M.  P.  Husband  was  killed  eighteen  months  before ; 
the  child  on  patient's  admission  was  eighteen  months,  so 
that  the  shock  of  the  husband's  death  must  have  come  on 
about  the  time  of  parturition.  She  weaned  the  child  three 
months  before  admission,  went  to  a  situation  a  week  before 
admission,  and  to  her  friends  she  then  appeared  to  be  all 
right.  The  situation,  with  its  new  duties — having  to  learn 
new  ways  and  acquire  new  habits — and  the  worry  which  is 
usually  associated  with  a  change  of  place,  seemed  to  be  the 
last  straw  in  the  production  of  this  attack. 

On  admission  she  was  intensely  excited,  very  bold  in  her 
manner,  outrageous,  immodest,  indecent  in  her  conduct. 
She  refused  food,  believing  it  was  poisoned.  She  had 
forgotten  that  her  husband  was  dead,  and  spoke  of  him  as 
if  alive  ;  she  was  anxious  about  the  children.  Her  excite- 
ment continued  day  and  night  for  a  long  time  ;  there  was 
ansemia  and  emaciation  ;  the  lips  and  tongue  were  dry.  She 
became  more  reckless  and  impulsive ;  she  wanted  to  burn 
her  hair.  Then  she  seemed  to  feel  pain  when  handled,  and 
cried  out  ;  but  no  swelling  was  noticed,  though  she  groaned 
when  she  rose,  as  if  the  muscles  or  joints  were  sore.  Later 
on  the  small  joints  of  the  feet  were  swollen,  and  salicylate 
of  soda  was  given  with  good  results.  Soon  after  this  the 
metacarpo-phalangeal  joints,  etc.,  became  swollen.  Anti- 
rheumatic treatment  was  again  persevered  with.  These 
symptoms  disappeared,  she  began  to  put  on  flesh,  and 
finally  recovered  after  she  had  been  insane  six  months. 


CHAPTER  XVII. 

CONSECUTIVE  OR  CONCOMITANT  INSANITIES. 

Asthma  in  relation  to  insanity — Bright's  disease — Cardiac  disease  — 
Different  lesions  and  different  mental  symptoms — Diabetes — Exoph- 
thalmos— Gout — Influenza — Insanity  and  lead-poisoning — Menstrual 
irregularities  and  insanity,  and  the  ordinary  effects  of  menstruation 
in  the  course  of  insanity — Myxcedema — Phthisis — The  form  known 
as  phthisical  insanity — Post-febrile  insanity — Raynaud's  disease — 
Rheumatism — Sunstroke — Uterine  disease  and  insanity. 

The  theory  of  metastasis^ — a  change  of  disease  from  one  site 
to  another — is  one  which  is  very  suggestive  to  those  who 
have  seen  much  of  insanity,  and  have  been  surprised  from 
time  to  time  by  the  intercurrence  of  acute  bodily  disease 
with  insanity.  Alternations  from  mental  to  bodily  disease 
undoubtedly  frequently  occur,  and  constitutional  disturbance 
of  a  very  grave  character  is  frequently  seen  in  asylums  to  be 
associated  with  an  alteration  of  the  mental  state,  which  may 
merely  consist  of  a  change  of  mood  or  temper,  a  partial 
clearing  up  of  the  intellect,  or  an  actual  recovery  for  a 
longer  or  shorter  period.  The  relation  of  bodily  to  mental 
disease  is  interesting  from  other  points  of  view.  In  attempts 
at  diagnosis  of  mental  disease,  the  symptoms  are  so  illusive, 
sometimes  so  difficult  to  ascertain,  and  often  so  difficult  to 
appraise  at  their  proper  diagnostic  value,  that  the  treatment 
of  such  cases  is  often  very  perplexing  and  disappointing.  It 
is  not  surprising,  therefore,  that  the  physician  in  general 
practice,  as  well  as  the  asylum  physician,  should  seize  on 
bodily  conditions  associated  with  insanity  as  something 
tangible,  something  which  may  have  a  relation  as  cause  to 
effect,  and  therefore  give  practical  suggestions  for  treatment. 
The  result  is  that  a  great  deal  has  been  written  on  the  rela- 


ASTHMA  AND  INSANITY  361 

tion  of  various  bodily  diseases  to  insanity,  and  attempts  have 
even  been  made  to  classify  insanity  in  the  light  of  its  rela- 
tion to  these  bodily  states.  It  is  not  my  purpose  to  advance 
any  argument  in  favour  of  such  a  theory.  That  some  bodily 
diseases  have  a  more  intimate  causal  relation  to  insanity 
than  others  is  undoubtedly  true,  but  we  know  that  many 
cases  of  the  kind  are  never  associated  with  even  nervous 
symptoms,  and  if  we  pushed  this  theory  to  its  logical  con- 
clusion, we  should  have  to  admit  either  that  the  theory  failed, 
or  that  there  must  have  been  associated  evidence  of  heredity 
or  mental  causation  in  the  cases  where  it  had  any  appearance 
of  justification  whatever.  We  cannot  as  yet  fix  on  a  sound 
code  of  causation,  and  it  is  not  surprising  that  we  should 
look  for  explanations  in  the  multitude  of  bodily  diseases 
which  have  a  material  realism  in  striking  contrast  Jo  mental 
disease. 

In  dealing,  therefore,  with  the  question  of  bodily  disease 
and  insanity,  it  must  not  be  supposed  that  I  am  committed 
to  a  belief  either  in  the  necessary  causal  relation  of  the  one 
to  the  other,  or  in  a  definite  group  of  symptoms  associated 
with  any  particular  bodily  disease.  The  following  series, 
arranged  alphabetically,  will  comprise  a  summary  of  facts 
observed  by  myself,  taken  from  the  clinical  experience  of 
many  writers,  and  intended  to  throw  light  on  the  relation 
of  mental  to  bodily  disease. 

Asthma. 

It  has  frequently  been  observed  by  Savage,  Conolly 
Norman,  and  others,  that  alternations  from  asthma  to 
insanity,  and  vice  versa,  are  liable  to  occur,  and  Conolly 
Norman  has  written  {Journal  of  Mental  Science,  1885)  a  full 
account  of  such  cases.  Summing  up  his  results  in  seven 
cases,  he  observes  :  '  All  the  foregoing  cases,  except  the  last, 
have  one  remarkable  feature  in  common — they  all  show  a 
marked  alternation  of  mental  and  pulmonary  symptoms. 
Thus,  in  the  first  case  we  have  chronic  asthma  vanishing 
when  insanity  comes  on,  and  reappearing  when  the  mental 
trouble  becomes  chronic.  In  the  second,  asthma  cuts  short 
and  takes  the  place  of  an  attack  of  insanity.     In  the  third. 


362  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

perhaps  the  most  remarkable  and  interesting  of  the  series, 
habitual  asthma  disappearing,  its  place  is  rapidly  taken  by 
insanity,  which  again  immediately  disappears  on  the  return 
of  the  asthma.  When  the  last  change  occurred,  the  patient 
was  under  close  observation  in  an  asylum,  so  that  there  can 
be  no  doubt  as  to  the  sequence  of  events.  It  would  pro- 
bably be  carrying  scepticism  too  far  to  say  that  the  cure  was 
due  to  the  action  of  expectant  attention  in  a  patient  already 
convalescent.  In  the  fourth  case,  chronic  asthma  occurring 
in  an  imbecile  ceases  with  an  acute  attack  of  insanity,  and 
comes  on  again  when  the  latter  has  passed  off.  In  the  fifth 
the  same  order  of  things  is  observed  as  in  the  third.  In  the 
sixth  chronic  asthma  lessens  in  severity,  and  finally  dis- 
appears with  the  oncome  of  insanity.  When  the  mental 
defect  becomes  chronic,  with  some  degree  of  amelioration, 
asthma  returns.  The  mental  symptoms  in  these  cases  were 
not  of  any  definite  character  ;  some  were  melancholic,  and 
one  was  a  case  of  acute  mania,  the  others  exhibited  the 
characteristics  of  chronic  mental  disease.'  '  In  three  cases 
of  Dr.  Savage's  there  was  a  history  of  phthisis  in  the  family.' 
This  is  of  special  interest,  from  the  fact  that  there  is  a  form 
of  insanity,  afterwards  to  be  described,  called  phthisical 
insanity. 

Bright's  Disease. 

It  is  a  matter  of  doubt  whether  Bright's  disease  occurs 
more  frequently  among  the  insane  or  not,  but  there  can  be 
no  question  that  albuminuria  is  not  infrequently  found  in 
such  cases,  and  post-mortem  examination,  if  carefully  con- 
ducted, not  infrequently  reveals  pathological  changes  of  a 
more  or  less  striking  character.  Dr.  Howden  Montrose  found 
fatty  degeneration  of  the  kidneys,  cysts,  and  albuminuria 
in  a  considerable  number  of  cases.  The  mental  symptoms 
seen  in  connection  with  Bright's  disease  may  be  maniacal  or 
melancholic.  Of  three  cases  described  by  Wilks,  two  seem 
to  have  been  associated  with  epileptiform  seizures,  and  all 
were  more  or  less  delirious,  if  not  maniacal.  According  to 
Clouston,  '  the  symptoms  are  those  of  mania  of  a  delirious 
,  kind,    with    extreme   restlessness,    delusions   as    to    persons 


BRIGHT S  DISEASE  AND  INSANITY  363 

being  round  the  patient,  and  absolute  want  of  fear  of  jumping 
through  windows,  or  other  actions  that  would  kill  or  injure.' 

The  following  is  a  summary  of  cases  recently  under 
treatment  : 

Mrs.  C.  B.,  set.  36 — Bright's  disease,  paroxysmal  mania,  refusal 
of  food,  ending  in  mild  dementia.  This  patient  has  been  insane 
for  about  a  year.  On  admission  from  another  asylum,  nearly 
a  year  ago,  the  report  was  :  '  She  is  very  unsettled,  rambles, 
is  often  incoherent  in  conversation,  and  shows  various  insane 
delusions,  such  as  that  she  is  Queen  Victoria,  that  another 
of  the  patients  here  was  put  into  a  cellar  below  her,  etc.  She 
refuses  food  because  she  is  "  feard  "  (afraid)  to  take  it.  Bodily 
health  and  condition  are  weak.  She  is  ansemic,  and  suffers 
from  albuminuria.' 

Before  coming  under  asylum  treatment  she  had  attempted 
to  jump  through  a  window.  For  the  first  few  months  of 
residence  here  she  was  excited,  noisy,  and  incoherent,  her 
attacks  coming  in  gusts.  Then  she  toned  down  into  a  state 
of  weak,  irrelevant,  inconsequent  mania,  without  any  expres- 
sion of  delusions.  Now  she  is  in  a  state  of  mild  dementia, 
but  her  bodily  health  is  much  improved. 

Mrs.  M.  G.,  aet.  '^y — Bright' s  disease,  ulcerative  tonsillitis, 
melancholia  with  fear  of  poison.  This  patient  was  admitted 
after  previous  treatment  for  Bright's  disease  in  the  Glasgow 
Royal  Infirmary,  the  throat  symptoms  appearing  after  ad- 
mission here. 

The  urine  was  loaded  with  albumen,  and  smoky  in  ap- 
pearance. Microscopic  examination  showed  red  corpuscles, 
granular  cells,  epithelial  and  granular  casts,  renal  and  tailed 
epithelium.  She  was  treated  at  first  with  milk  diet,  but 
there  was  no  improvement.  Afterwards  she  was  put  on 
ordinary  diet,  and  this  change  was  followed  by  a  marked 
diminution  in  the  amount  of  albumen  present  in  the  urine, 
and  a  considerable  improvement  in  her  physical  health. 

She  had  a  sad  expression,  also  a  weak  memory.  She  took 
no  interest  in  her  surroundings,  but  refused  food,  believing 
it  to  be  poisoned.  She  threatened  the  lives  of  her  children, 
and  was  sleepless.  She  was  very  much  afraid  of  something 
about  to  happen,  and  asked  us  if  she  was  to  be  blown  up  with 


364  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

dynamite.  She  is  now  convalescent,  though  still  somewhat 
depressed. 

M.  E.,  get.  26 — hysteria,  catalepsy,  melancholia,  anaemia, 
Bnghfs  disease,  fear  of  poisoning.  This  patient,  under  the 
influence  of  insane  fear,  developed  delusions,  e.g.,  that  her 
food  was  poisoned  by  her  uncle,  and  that  she  was  pursued 
by  the  Evil  One,  whom  she  addressed  as  Lucifer.  She  refused 
food,  and  kept  continually  praying  and  calling  out,  '  Jesus, 
Mary,  Joseph  !'  Before  admission  she  suffered  from  hysteria 
and  catalepsy.  She  suffered,  and  still  suffers,  from  oedema, 
albuminuria,  anaemia,  and  other  symptoms  of  Bright's 
disease. 

From  these  observations,  it  must  be  manifest  that  no 
special  group  of  symptoms  can  be  looked  for,  but  it  is 
evident,  from  the  three  cases  which  have  just  been  described, 
that  in  them,  at  least,  there  was  fear  or  delusions  of  poison- 
ing, and  melancholia  was  the  more  prevalent  form. 

The  effect  of  this  disease  on  the  arterial  system,  on  the 
heart,  and  the  state  of  the  blood,  must  naturally  predispose 
to  brain  lesion,  or  at  least  to  brain  anaemia,  and  the  cases 
which  I  have  seen  have  partaken  more  often  of  the  melan- 
cholic than  of  the  maniacal  type. 

Cardiac  Disease. 

Dr.  T.  D.  Greenlees,  writing  on  cardiac  disease  in  the 
insane,  observes  that  6'6g  per  cent,  of  the  deaths  in  English 
asylums  were  due  to  heart  disease ;  but  the  prevalence  of 
cardiac  disease  with  insanity,  as  he  is  careful  to  point  out, 
must  vary  in  different  districts,  for  the  geographical  and  the 
geological  factors  require  to  be  taken  into  account.  In  my 
experience,  the  proportion  of  cases  of  heart  disease,  as 
ascertained  by  examination  on  admission,  and  in  several 
cases  verified  post-mortem,  is  not  less  than  20  per  cent. 
According  to  Mickle,  the  following  mental  symptoms  are 
generally  associated  with  particular  forms  of  cardiac  and 
arterial  disease  : 

Mitral  regurgitation,  with  some  degree  of  mental  depres- 
sion, together  with  delusions  of  suspicion  and  persecution. 
This  experience  I  can  confirm  from  notes  of  several  cases. 


CARDIAC  DISEASE  IN  THE  INSANE  365 

but  the  delusions  of  persecution  were  not  so  frequent  as  in 
Mickle's  experience,  and  there  was  a  strong  suicidal  tendency 
in  some  cases. 

Mitral  Stenosis. — The  patients  are  frequently  excitable,  im- 
pulsive, querulous,  and  most  difficult  to  manage. 

A  ortic  Regfi,rgitation. — Such  cases  are  often  excitable,  sleep- 
less, and  restless.  They  are  frequently  subject  to  delusions  of 
an  exalted  character,  and  not  infrequently  manifest  hallucina- 
tions with  other  perversions  of  the  senses. 

Aortic  Stenosis.  —  This  disease  is  often  associated  with 
excitement,  sometimes  with  general  paralysis ;  the  patient 
is  violent  and  impulsive,  and  sometimes  subject  to  delusions 
of  persecution,  or  that  his  food  is  poisoned. 

No  very  definite  conclusion  can  be  drawn  from  this  list  of 
symptoms,  and  I  have  not  been  able  to  elucidate  the  matter 
by  a  study  of  fifty  cases  under  treatment  during  i8g6.  The 
following  results  are  interesting,  however.  In  over  30  per 
cent,  of  epileptics  we  found  heart  disease,  80  per  cent,  ex- 
hibiting mitral  disease,  12  per  cent,  aortic  disease.  While 
mitral  disease  is  associated  with  melancholia  in  the  majority 
of  cases,  there  is  a  considerable  minority  of  mitral  cases 
suffering  from  mania.  Aortic  disease  is  usually  associated 
with  mania.  We  found  no  general  paralytic  with  aortic 
disease,  but  in  a  large  proportion  of  the  male  cases  there  was 
evidence  of  mitral  incompetence.  One  man  suffering  from 
mitral  incompetence  was  twice  insane,  in  the  first  instance 
presenting  symptoms  of  melancholia,  in  the  second  of  mania. 
Many  cases  of  heart  disease  which  are  subject  to  chronic  or 
recurrent  excitement  live  for  a  long  time  without  failure  of 
compensation,  and  this  may  seem  strange,  because  excite- 
ment is  regarded  as  dangerous  to  patients  having  heart 
disease.  We  have  cases  of  noisy  excitement,  singing,  laugh- 
ing, shouting,  scolding  incessantly,  and  yet  they  seem  none 
the  worse  after  a  lapse  of  fifteen  years.  But  these  are  chronic 
cases ;  the  excitement  is  automatic,  and  quite  disconnected 
from  the  original  state  of  feeling  which  gave  it  birth,  and 
which  is  now  impersonal  and  dispassionate,  if  not  actually 
dead. 


366  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

Diabetes  and  Insanity. 

The  mental  relations  of  diabetes  have  received  considerable 
attention,  and  in  general  practice  mental  and  nervous  changes 
are  frequently  noticed  and  looked  for.  The  origin  of  diabetes 
is  essentially  a  nervous  one,  and  Maudsley  and  Savage  have 
drawn  attention  to  the  intimate  family  relation  between  it  and 
insanity.  Short,  however,  of  actual  insanit}^  niay  be  observed 
characteristic  mental  symptoms.  The  literature  of  insanity 
does  not  furnish  many  cases,  because  diabetes  itself  is  rare, 
but  undoubtedly  there  is  a  tendency  towards  mental  disease 
in  well-marked  cases  of  diabetes.  In  Clouston's  cases  melan- 
cholia was  well  marked,  and  the  characteristic  mental  torpor, 
a  mental  weariness,  or,  as  Lasegue  has  it,  '  the  loss  of 
appetite  for  thought.'  It  is  natural  in  such  cases,  so  long 
as  there  is  any  capacity  for  mental  thought  left,  that  the 
mind  should  be  self-centred,  and  that  the  patient  should 
brood,  and  fix  his  attention  on  the  distinctive  feature  of  his 
disease,  the  excessive  formation  of  sugar.  This  being  so,  it 
is  not  surprising  that  the  melancholy  should  often  take  on 
the  hypochondriacal  form,  and  this  is  well  brought  out  by 
Regis  in  his  '  Manual  of  Mental  Medicine.'  Diabetic  insanity 
is  thus  described  by  him  :  '  The  mental  state  of  diabetics 
reveals  itself  in  general  by  hypochondria,  torpor,  or  symptoms 
of  invincible  somnolence,  fears  of  ruin  or  misfortune,  motive- 
less prepossessions,  and  tendency  to  suicide.  The  hypo- 
chondria here  necessarily  assumes  a  peculiar  character;  it 
has  for  its  object  the  presence  of  sugar  in  the  urine,  and 
impels  the  patient  to  examine  it,  to  taste  it,  to  multiply 
analyses,  and  to  discuss  the  proportion  of  glucose  and  the 
make-up  of  the  dietar}^  regimen  to  the  exclusion  of  all  other 
subjects.  It  is  to  be  remarked  that  this  hypochondria  is  in 
direct  ratio  with  the  amount  of  sugar  excreted,  as  it  improves 
as  the  sugar  decreases.'  Clouston  sums  up  his  description 
of  two  cases  of  diabetic  insanity  as  follows :  '  These  two 
cases  of  diabetes  had  many  mental  symptoms  in  common, 
though  they  had  some  differences.  They  were  both  melan- 
cholic. They  both  imagined  they  had  no  mone}',  that  they 
were  ruined,  and  could  not  pay  their  debts.     They  both  had 


DIABETES  AND  EXOPHTHALMOS  WITH  INSANITY    367 

a  disinclination  to  take  food.  They  were  both  wanting  in 
affection  for  their  children.  They  both  were  thin  and  weak. 
They  both  had  a  tendency  to  sores  on  extremities,  with  small 
healing  power;  but  the  one  was  resistive  and  dogged  ;  and  the 
other  more  passive,  inattentive,  and  uninterested  in  anything 
in  the  world.  Death  in  both  cases  occurred  rather  suddenly.' 
Dr.  Savage  observes  that  a  patient  may  suffer  from  diabetes  for 
a  time,  and  may  become  insane,  the  symptoms  of  diabetes 
disappearing,  only  to  reappear  on  recovery  from  the  insanity. 
He  has  observed  glycosuria  in  puerperal  insanity,  but  I  have 
been  unable  to  confirm  this  from  my  experience.  In  one 
case  at  present  under  my  care — the  case  of  a  woman  who 
has  been  insane  for  nearly  forty  years,  and  who  is  exceed- 
ingly demented — diabetes  mellitus  has  appeared  with  all  the 
characteristic  symptoms  of  the  excessive  formation  of  sugar, 
polyuria,  dry  skin,  great  thirst  and  appetite.  In  another 
patient — a  male  who  has  been  always  a  little  weak-minded — 
diabetes  insipidus  has  made  its  appearance.  His  thirst  is  ex- 
treme, his  cheeks  are  now  suffused  with  a  delicate  blush  all 
the  time,  and  he  has  suffered  from  a  severe  boil  in  the  neck. 

Exophthalmos. 

In  the  Journal  of  Mental  Science,  June,  1884,  ^^-  Carlyle 
Johnstone  gave  a  very  complete  description  of  a  case  of 
exophthalmic  goitre  with  mania.  In  summing  up,  he 
remarked  '  that  psychical  disturbances  have  always  been 
common  in  cases  of  exophthalmic  goitre,  and  instances  of 
actual  insanity  have  been  recorded.'  The  irritability,  capri- 
ciousness,  mental  excitability,  the  hysterical  manifestations, 
the  alternations  of  excitement  and  depression,  characteristic 
of  the  disease  were  all  present  in  the  cases  which  he  recorded, 
and  aggravated  even  to  the  extent  of  acute  mania.  Rapid 
pulse  and  prominent  eyeballs  are  symptoms  found  associated 
with  recent  insanity,  and  also  with  general  paralysis  of  the 
insane.  In  Johnstone's  case  lactation  stopped  four  months 
after  the  birth  of  her  child.  It  was  evidently  an  exhausting 
process,  as  the  patient  had  been  losing  flesh  some  time 
previously.  In  one  case  of  melancholia  from  hyper-lacta- 
tion under  my  care  recently,  exophthalmos  was  observed, 
though  the  size   of  the  thyroid  gland  was   not  appreciably 


368  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

enlarged.  The  patient  was  distinctly  melancholic ;  there 
was  no  irritability,  excitement,  or  violence  ;  no  hysterical 
symptoms,  merely  a  dull  melanchoty,  which  disappeared  as 
the  bodily  health  was  restored.  The  exophthalmos  also 
subsided  very  much  after,  only  a  staring  expression  of  the 
eyeballs  remaining.  In  another  patient  we  found  it  asso- 
ciated with  enlarged  th3Toid  and  enlarged  heart,  also  a  case 
of  melancholia,  but  the  goitre  really  was  in  this  case  the 
more  striking  condition. 

For  further  observations,  vide  Turnbull,  Journal  of  Mental 
Science,  vol.  xxxvi. 

Gout  and  Insanity. 

On  this  subject  the  late  Sir  Russell  Reynolds,  in  December, 
1877,  published  his  views  in  the  British  Medical  Journal,  and 
the  following  summary  gives  a  practical  resume  oi  the  subject: 

'Mental  Disturbances  of  Gouty  Origin. — Many  cases  have 
come  before  me  in  which  there  was  great  restlessness  ;  the 
patient  could  not  be  still  for  a  moment,  was  alternately 
excited  and  depressed,  slept  badly  or  not  at  all,  was  in- 
tensely hysterical,  and  could  not  attend  to  business,  while 
others  have  complained  of  failing  memory,  of  want  of  power 
of  attention,  of  suicidal  thoughts,  of  intense  melancholy ; 
others  of  sounds  in  the  ears,  voices  sometimes  distinct, 
sometimes  not,  and  some  or  all  of  these  in  maniacal  con- 
ditions, but  vet  all  disappearing  under  treatment  upon  the 
hypothesis  I  have  mentioned.  These  symptoms  often  alter- 
nate with  or  accompany  pains  in  the  head,  and  certain  minor 
sensations.  Some  of  the  most  intense  head  pain  that  I  have 
met  with  has  been  of  this  character,  and  been  relieved  by 
treatment  of  an  anti-gouty  description.  The  special  features 
are  pain  on  one  side  of  the  head,  usually  parietal  or  occipital, 
grinding  habitually,  but  forced  into  almost  intolerable  severity 
by  movement,  such  as  the  jar  of  carriage-riding  or  running 
down  the  stairs  of  a  house,  and  this  is  without  any  over- 
sensitive nerve-points,  without  tenderness  of  the  scalp,  and 
without  any  aggravation  by  mental  exertion.  Various  modified 
sensations  occur,  such  as  vertigo,  which  is  the  most  common, 
and  may  exist  alone.     It  is  sometimes  determined  by  posture. 


GOUT  AND  INSANITY  369 

With  it  is  often  associated  deafness,  noise  in  the  ears,  and 
a  feehng  of  "  beating  in  the  ear."  With  vertigo  and  tinnitus 
there  may  be  much  mental  depression  or  attacks  of  bewilder- 
ment, amounting  sometimes  to  those  of  le  petit  mal.  These 
modified  sensations  are  most  variable  in  their  kind  and  their 
locality,  and  this  wide  distribution  and  variability  is  by  no 
means  a  bad  sign.' 

The  correlations  of  insanity  and  gout  are  fully  and 
succinctly  set  forth  by  Dr.  Rayner  in  a  well  -  digested 
summary  written  for  Tuke's  '  Dictionary  of  Psychological 
Medicine.'  There  is  given  in  the  article  a  broad  general  view 
of  the  subject,  and  a  distinction  is  drawn  between  cases 
occurring  in  association  with  active  gout  and  cases  asso- 
ciated with  suppressed  gout.  The  symptoms  are  of  no 
uniform  character,  although  melancholy  seems  to  be  in 
frequent  association  with  this  disease.  There  have  been 
observed  examples  of  simple  delusional  and  suicidal  melan- 
cholia as  well  as  the  stuporose  form.  There  have  also  been 
observed  cases  of  mania  with  epilepsy  and  hallucinations,  as 
well  as  simple  and  paralytic  dementia.  Retrocession  of  gout, 
as  Rayner  observes,  is  a  well-recognised  cause  of  apoplexy ; 
but  it  might  also  result  in  mania  with  or  without  epileptiform 
seizures,  and  in  other  mental  disturbance.  Cases  are  quoted 
from  Garrod — one  of  a  gentleman  aged  seventy,  in  whom  the 
sudden  disappearance  of  gout  from  one  wrist  was  followed 
by  mental  disorder  for  three  weeks,  which  ceased  on  the 
reappearance  of  the  gout.  Another  was  the  case  of  a  clergy- 
man aged  sixty,  a  great  martyr  to  gout,  who,  when  slightly 
recovering  from  a  moderately  acute  attack  in  the  feet,  went 
to  his  church  and  officiated  on  a  very  cold  day.  After  the 
service  he  took  train  to  London,  where  he  was  found  a  few 
days  later  quite  insane.  He  recovered.  One  of  the  most 
striking  in  Rayner's  experience  was  that  of  a  man  who,  after 
protracted  gout  for  which  he  had  taken  large  quantities  of 
medicine  of  his  own  prescribing,  developed  delusions  founded 
on  hallucinations.  In  a  short  time  he  became  stuporose, 
and  was  sent  to  Hanwell.  He  was  extremely  weak  on 
admission,  and  had  not  spoken  for  weeks.  Hot-air  baths 
were  given  with  great  benefit.      During  one  of  the  earliest 

24 


370  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

exhibitions  of  this  treatment,  he  spoke  for  the  first  time. 
Under  their  use  he  soon  developed  severe  acute  attacks  of 
gout,  and  convalesced  rapidly. 

Influenza  and  Insanity. 

A  considerable  amount  of  interest  has  been  aroused  b}' 
the  subtle  and  mysterious  encroachments  of  influenza  on  the 
nervous  system,  and  its  undoubted  influence  on  the  mind;  but 
many  doubt  the  propriety  of  using  the  term  '  post-influenzal 
insanity,'  as  signifying  cause  and  effect.  There  can,  however, 
be  no  question  of  this,  that  as  a  contributory  cause  influenza 
is  a  factor  of  the  utmost  importance.  The  manifestations  of 
influenza  in  relation  to  sanity  and  insanity  have  received 
very  great  attention  in  asylums,  where  the  medical  officers 
have  had  ample  opportunities  of  judging  of  the  effects  of  this 
epidemic  disease  on  the  sane  as  well  as  the  insane.  Before 
enumerating  the  mental  symptoms  which  may  characterize 
insanity  following  influenza,  it  is  desirable  that  I  should 
emphasize  the  fact  that  the  disease  has  a  special  affinity 
for  nervous  tissues,  for  the  brain  in  particular,  and  that  it 
frequently  gives  rise  to  head  symptoms  of  an  alarming  kind. 
Many  patients  who  have  suffered  from  influenza  talk  of  it 
with  bated  breath  and  superstitious  fear,  and  not  a  few  have 
been  shattered  nervous  wrecks  for  a  long  time  after,  if  not 
permanentl}'.  There  is  noticed  a  nervousness  afterwards, 
motor  and  sensory,  vague  fears  difficult  to  explain,  impaired 
memor}^  sleeplessness,  a  nervous  feeling  of  something  im- 
pending, in  some  a  dread  that  reason  may  be  dethroned, 
vertigo,  and  other  nervous  and  mental  features  in  many 
cases.  I  have  known  a  strong,  healthy,  temperate  man 
without  any  apparent  nervousness  previous  to  his  attack, 
without  any  family  history  of  nervous  disease  recover,  and 
then  relapse  into  a  temporar}-  state  of  mental  weakness  and 
excitability  in  which  he  was  confused,  unable  to  concentrate 
attention,  or  make  a  simple  calculation,  and  subject  to  fits  of 
terror,  as  if  suffering  from  delirium  tremens.  He  was  so 
much  the  prey  of  hallucinations  that  he  attempted  to  jump 
out  of  a  window.  With  friends  to  sit  beside  him  for  a  couple 
of  nights,  he   was  safely  guarded. from   self-injury,   and   he 


INFLUENZA  AND  INSANITY  371 

passed  out  of  this  state  with  a  certain  nervousness  and  fear 
that  some  day.  he  might  become  insane.     This  led  to  his  effect- 
ing a  change  of  occupation,  and  he  is  now  quite  well  and  strong. 
Professor    Kirn,    of   Freiburg    {Allgenieine    Zeitschrift   fiir 
Psychiatric,  Band  xlviii.,  Heft  i  and  2),  affirmed  the  opinion 
that  influenza  in  his  experience  was  a  more  frequent  exciting 
cause    of    insanity    than    any    other    febrile    affection.       He 
summed  up  from  the  collected  records    of  fifty-four  cases 
observed   by    himself    and    others.     In    the    first    place,    he 
noticed  what  is  now  matter  of  common  experience  with  all 
physicians,  that  nervous  symptoms  are  prominent  in  ordinary 
cases  of  influenza.     There  are  headache,  sleeplessness,  pains 
in  the    limbs,   and   neuralgia,  with  great  prostration.     The 
forms  of  insanity  he  recognises  as  coming  under  two  heads  : 
First,  where    delirium   occurs    during   the    febrile    condition 
of  influenza,  being   frequently   associated  with   pneumonia. 
There    are    delusions    and    hallucinations,    strange    dreams, 
boisterous    exaltation,   or   bowlings    and    lamentations.      He 
observes    that    patients    affected   with    delirium    during    the 
acute   course  of  the  disease  were  rarely  found  to  have  any 
hereditary  predisposition  to  insanity.     In  the  second  or  post- 
febrile form  he  obtained  details  of  thirty-nine  cases.     The 
insanity  generally  appeared  in  from  four  to  eight  days  after 
the  cessation  of  the  fever,  although  in  some  cases  it  came 
on    as    late    as   three  weeks   after.     He    groups   the   mental 
symptoms   under   three   heads  :    mental   exhaustion,    melan- 
cholia, and  mania.     The  exhaustion  is  of  the  same  character 
as  in  those  cases  where  the  constitution  of  the  patient  has 
been  reduced  by  fever  or  the  puerperal  state.     He  regards 
the    melancholic    form    as    the    commonest.      Here   there   is 
sleeplessness    as   the   first    symptom,    then   discontent,   with 
reproaches  against  the  attendants  and  distrust  and  suspicion 
against  the  physician.     The  patient  is  hypochondriacal,  fears 
ruin,  loss  of  money  or  loss  of  honour,  and  occasionally  there 
are  attempts  at  suicide,  frightful  hallucinations,  painful  delu- 
sions, and  refusal  of  food.     Of  the  maniacal  group  nothing 
particular  or  characteristic  can   be  stated.     The  symptoms 
were  those  of  typical  mania,  and  recovery  occurred  in  about 
two  months. 

24 — 2 


372  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

Insanity  and  Lead- poisoning. 

The  pathogenic  influence  of  lead  on  the  nervous  system 
has  long  been  recognised,  but  only  of  late  years  has  atten- 
tion been  directed  to  the  association  of  lead-poisoning  with 
mental  changes.  The  nervous  symptoms,  when  insanity 
appears,  are  not  always  so  diffuse  or  well  marked  as  might 
be  expected.  In  some  cases  there  is  no  wrist-drop  noticed 
at  all,  but  one  phenomenal  and  striking  nervous  change  has 
been  observed  by  Dr.  Hale  White,  Dr.  Alexander  Robert- 
son and  others,  viz.,  epileptic  or  epileptiform  seizures.  In 
some  cases  also,  as  observed  b}'  Dr.  Ruxton  and  myself,  loss 
of  memory,  especially  for  proper  names  and  recent  events, 
has  been  remarkable.  In  other  cases  confusion  may  arise 
owing  to  a  complication  of  causes,  e.g.,  alcoholic  excess  as 
well  as  lead-poisoning.  These  were  combined  in  the  history 
of  the  case  which  I  reported  in  the  Journal  of  Mental  Science, 
October,  1883.  There  was  also  a  history  of  slight  injury  to 
the  head,  but  after  the  mental  excitement,  which  had  been 
due  to  a  fit  of  drinking,  passed  off,  and  the  tremor  had  dis- 
appeared, there  still  remained  a  decided  weakness  of  memory, 
an  inability  to  register  and  recall  at  will  new  impressions. 
This  patient,  long  after  he  was  well  in  all  other  respects,  so 
suffered  from  impaired  memory  that  he  was  unable  to  take 
his  former  place  as  a  foreman  painter.  He  required  constant 
supervision  in  his  work,  because  he  was  apt  to  forget  himself 
and  get  lost  in  a  kind  of  maze.  Dr.  Robertson's  cases  are 
very  interesting  from  the  fact  that  they  both  occurred  in 
young  girls,  and  there  was  more  or  less  atrophy  of  the  optic 
discs  in  both  cases.  Noisy  delirium,  which  continued  for 
five  weeks,  characterized  the  one  case,  and  although  she 
ultimately  recovered,  the  hearing  was  impaired,  and  the 
sight  was  apparently  irretrievably  lost.  In  the  other  case, 
four  days  before  admission  to  the  hospital,  the  patient  was 
seized  with  convulsions,  and  within  two  hours  had  six  fits. 
Three  other  fits  occurred  during  the  first  week  of  her 
residence,  but  no  more  prior  to  her  dismissal  about  a  month 
afterwards.  According  to  Rayner,  mental  disorder  from  lead- 
intoxication  does  not  occur  without  an  antecedent  period  of 


INSANITY  AND  LEAD-POISONING  373 


premonitory  symptoms.  These  consist  of  headache,  wake- 
fulness, disturbed  sleep,  and  some  terrifying  dreams  with 
sensory  derangements,  especially  tinnitus  aurium,  and  flashes 
of  light  before  the  eye,  together  with  slowness  of  ideation  and 
depression  of  spirits.  Delirium,  either  of  a  melancholic  or 
maniacal  character,  appears  to  be  very  frequent  in  these 
cases.  In  the  Journal  of  Mental  Science,  1880,  Rayner  re- 
corded cases  in  which  there  was  a  gradual  evolution  of 
hallucinations  and  chronic  insanity  which  did  not  differ 
from  similar  disorder  produced  by  alcoholic  tippling  except 
in  the  marked  wrinkling  of  the  face  in  two  cases,  and  by  the 
greater  persistence  and  predominance  of  visual  hallucinations 
and  motorial  troubles  (startings  and  tremors).  The  prog- 
nosis is  given  by  Rayner  as  follows  :  The  cases  of  nocturnal 
delirium  may  recover  at  once.  The  continued  delirium,  if 
arrested  within  three  or  four  days,  convalesces  in  a  week  or 
two,  but  if  more  protracted,  convalescence  may  not  be  com- 
plete for  two  or  three  months.  Dr.  McDowall  Morpeth 
observed  that  in  Newcastle,  where  there  are  many  lead- 
works,  dementia  of  a  very  serious  type  has  been  found  to 
occur  as  the  result  of  lead-poisoning.  It  has  been  found 
that,  if  the  treatment  usually  prescribed  is  employed,  the 
results  are  disastrous,  and  according  to  McDowall,  '  if  iodide 
of  potassium  were  given  in  very  severe  cases,  the  patient 
would  pass  into  a  state  of  coma  and  die  quickly.'  Copious 
diluents,  sulphur  baths,  a  diet  which  best  favours  elimina- 
tion, and  attention  to  the  excretory  channels,  are  the  principal 
indications. 

Menstrual  Irregularities  and  Insanity. 

The  alteration  in  the  moods  and  tenses  of  the  sane  woman 
during  normal  menstruation  is  sufficient  proof  of  the  quick- 
ness of  mental  response  to  the  exercise  of  this  function.  It 
does  not  of  necessity  follow  that,  because  of  this  responsive- 
ness under  normal  conditions,  the  responsiveness  should  be 
exaggerated  under  abnormal  conditions.  The  varieties  of 
menstrual  irregularities  have  to  be  taken  into  account,  the 
difference  in  their  physiological  effects,  their  causation,  and 
their  precise  relation  in  point  of  time  to  the  outbreak  of  a 


374  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

mental  attack.  Thus,  for  example,  we  get  such  a  history  as 
the  following  :  A  girl  of  nineteen  has  not  been  strong  ;  she 
has  studied  hard,  menstruated  regularly,  but  too  freely  ;  be- 
came insane — acute  hysterical  mania — then  menstruation 
ceased.  She  is  convalescent  in  three  months  ;  the  menses 
have  not  yet  reappeared,  but  she  is  still  rather  anaemic  and 
below  par  physically.  A  month  later  a  scanty  flow  occurs, 
at  next  period  more  profusety,  and  thereafter  it  is  normally  re- 
established. Is  this  a  case  of  amenorrhoeal  insanity  ?  Most 
certainly  not.  Is  it  a  case  of  insanity  following  menorrhagia  ? 
Surely  not.  The  menorrhagia,  if  such  it  can  be  called,  was 
as  likely  a  nervous  sequel,  a  link  in  the  chain  of  events 
leading  up  to  the  attack  of  insanitv. 

Anaemia  and  amenorrhoea  are  sometimes  regarded  sepa- 
rately or  conjointly  as  causes  of  insanity  ;  but  whatever  im- 
portance we  may  concede  to  anaemia  in  this  respect,  there  is 
not  much  to  be  attached  to  amenorrhoea.  The  personal 
equation  is  the  all-important  point  for  decision  here,  and  the 
personal  equation  in  many  cases  of  insanity  with  menstrual 
irregularity  is  one  highly  neurotic  and  hysterical  to  begin 
with,  and  the  menstrual  changes  are  mere  aggravating 
incidents  in  not  a  few  cases.  We  meet  with  cases  where 
suppression  of  menstruation  immediately  preceded  an  attack 
of  mental  excitement,  and  with  other  cases  in  which  the 
menses  were  in  evidence  up  to  the  time  of  the  mental  attack, 
but  not  after.  On  the  principle  of  post  hoc  ergo  propter  hoc, 
should  we  regard  the  former  as  amenorrhoeal  insanity,  and 
the  latter  not  ? 

If  there  is  anything  in  the  theory  of  circulatory  metastasis, 
a  diversion  of  the  blood  current  from  one  locus  to  another, 
we  would  as  readily  assume  that  central  disturbance  was 
rather  the  cause  of  amenorrhoea  than  the  effect.  All  this 
notwithstanding,  we  have  to  a.dmit  that  cases  do  occasionally 
arise  in  which  a  distinct  history  of  amenorrhoea  is  manifest 
before  the  appearance  of  nervous  and  mental  symptoms. 
There  are  also  cases  in  which  the  suppression  of  the 
menstrual  flux,  whether  of  mental  origin — as  from  shock — 
or  not;  by  reaction  operates  injuriously  on  the  mind.  Most 
medical  men  are  familiar  with  cases  where  the  hot  sitz  bath, 


MENSTRUAL  IRREGULARITIES  AND  INSANITY       375 

with  perhaps  the  gentle  stimulation  of  a  little  mustard,  has 
promoted  menstruation  and  relieved  the  tension  of  the 
nervous  system,  which  threatened  to  break  away  in  the  form 
of  hysteria  or  mania. 

The  relation  of  menstrual  irregularity  to  anaemia  is  such 
that  the  two  are  most  frequently  associated,  though  the 
chronological  sequences  are  not  always  the  same.  In  some 
cases,  as  in  chlorosis,  there  is  perhaps  a  primary  neurosis. 
By  Trousseau  it  was  regarded  as  essentially  a  nervous 
disease,  having  its  origin  usually  at  the  time  of  puberty. 
Anaemia  and  menstrual  irregularities  he  regarded  as  secondary 
and  sequential ;  but  it  is  possible,  nay  probable,  that  he 
rather  underestimated  their  importance.  That  an  intimate 
relation  exists  between  the  mind  and  blood  nutrition  is  an 
undoubted  fact,  and  nowhere  is  this  better  illustrated  than 
in  the  lives  of  hospital  and  asylum  nurses.  Worry,  anxiety, 
and  prolonged  strain  frequently  bring  on  anaemia  with 
neuralgia,  sleeplessness,  and  menstrual  irregularity — not 
necessarily  amenorrhoea,  for  in  many  cases  menstruation  is 
too  frequent  and  too  profuse. 

Amenorrhoea  is  not  infrequently  associated  with  insanity 
of  adolescence,  but  it  would  be  absurd  to  speak  of  it  there- 
fore as  amenorrhoeal  insanity.  In  some  cases  we  find 
suppression  at  the  outset,  in  others  after  the  onset  of  the 
attack  ;  while  in  a  third  class  of  cases  I  have  found  that  the 
flow,  at  first  normal,  becomes  more  and  more  scanty  until  it 
disappears  altogether.  In  young  women  I  have  found  stupor, 
amenorrhoea  and  phthisis  all  associated  together.  The 
frequency  of  dysmenorrhoea,  combined  with  insanity,  is  dif- 
ficult to  determine.  Its  essential  symptom,  excessive  pain, 
is  for  obvious  reasons  an  unknown  quantity  in  many  cases  ; 
but  judging  from  the  evidence  that  is  available,  it  does  not 
appear  to  be  so  frequent  as  we  find  it  in  the  experience  of 
general  practice.  It  must,  however,  be  remembered  that  in 
states  of  mental  excitement  the  patient  is  more  or  less 
oblivious  of  pain.  Menorrhagia  is  a  condition  prone  to  arise 
at  the  climacteric,  but  in  younger  cases  I  have  been  surprised 
to  find  it  not  at  all  infrequent. 

There  are  no  special  forms  of  insanity  expressive  of  par- 


376  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

ticular  t3-pes  of  menstrual  irregularity,  nor  are  the  mental 
characters  the  same  in  immediate  relation  to  the  onset  of 
the  flow.  In  observations  made  regarding  physical  and 
mental  changes  before,  during,  and  after  menstruation,  it 
was  noted  that  disturbance  was  most  noticeable  for  a  da}- 
or  two  before  the  period,  less  marked  as  a  rule — some, 
however,  were  worse — during  menstruation,  and  least  notice- 
able, usuall}-  absent,  after  it  was  over.  Failure  of  appetite, 
headache,  constipation,  sleeplessness,  suspicion,  irritabilit}^, 
and  impulsiveness,  were  obser\-ed  in  the  first  stage  men- 
tioned ;  indeed,  the  mental  state  was  more  or  less  ex- 
aggerated, or,  instead  of  the  foregoing  mental  symptoms, 
stupor  or  mental  depression  attracted  attention. 

Myxcedema  and  Insanity. 

Since  the  late  Sir  William  Gull  directed  attention  to  what 
he  called  a  '  cretinoid  degeneration  in  adults,'  considerable 
interest  has  been  taken  in  the  disease,  which  is  now  known 
as  myxcedema.  Cases  occurred  in  as3-lums  the  nature  of 
which  was  not  suspected  until  the  researches  of  Gull  and 
Ord  were  made  public,  and  cases  also  occur  in  asylums 
where  myxcedema  is  secondan,'  to  the  mental  disease  instead 
of  being  the  primar}^  condition.  It  is  now  well  known  that 
m3-xcedema  has  mental  symptoms  of  its  own  long  before 
there  is  an}'  suspicion  of  insanity  in  the  case.  Whether 
these  are  due  to  sensor}'  changes,  induced  by  peripheral 
modifications  of  the  cutaneous  tissue  with  altered  conduc- 
tion of  sensory  impressions,  has  not  yet  been  settled.  Ac- 
cording to  Dr.  Ord,  the  mental  dulness  is  due  to  the  padding 
of  the  peripheral  extremities  of  the  nerve,  so  that  there  is 
imperfection  of  peripheral  conduction,  and  the  mind  is 
starved  of  appropriate  sensations :  but  it  is  more  than 
probable  that  there  are  also  changes  in  the  ner\-ous  or 
interstitial  substance  of  the  brain  itself.  The  disease  usually 
occurs  in  the  female  sex,  though  not  always  so,  and  it 
frequently  results  in  a  negative  mental  state,  an  obscuration 
of  the  mental  faculties,  a  slowness  of  mental  processes,  a 
condition  of  somnolence,  and  a  slow,  half-awake  speech.  It 
is  not  surprising  also  that  the  changes  which  alter  the  whole 


MYXCEDEMA  AND  INSANITY  377 

appearance  of  a  woman,  take  away  her  comeliness  and 
replace  it  by  a  fat,  unwieldy  appearance,  should  have  a 
direct  influence  on  the  mental  condition.  There  is,  there- 
fore, mental  depression  in  some  cases  with  suspicions,  and 
it  may  be  delusions  of  persecution. 

The  following  is  a  brief  summary  of  a  case  detailed  by 
Monsieur  Blaise,  which  may  be  found  in  the  Journal  of 
Mental  Science,  January,  1883  :  It  was  the  case  of  a  woman 
aged  thirty-four.  She  had  always  been  very  stout  since  men- 
struation, at  the  age  of  eleven,  and  about  the  age  of  twenty- 
one  the  affection  commenced.  Her  character,  which  was 
boisterous  up  to  the  age  of  twelve,  changed  and  became 
gentle.  She  led  an  active  life  up  to  her  majority.  Her 
intelligence  appeared  lively,  and  her  speech  was  exceedingly 
rapid.  Up  to  the  age  of  twenty-seven  she  presented  the 
same  appearance.  Then  she  increased  in  size  in  different 
parts  of  the  body,  experienced  strange  sensations,  had  fre- 
quent headaches  and  pains  in  the  malar  bones.  Her  character 
altered ;  she  became  restless,  the  speech  slow,  thick,  and 
with  a  peculiar  timbre.  She  entered  the  Montpellier  Asylum 
January,  1878.  At  first  her  judgment  rectified  the  errors 
of  sensation,  but  by  degrees  she  began  to  believe  in  her 
illusions  and  hallucinations.  At  last  she  fancied  she  wore 
a  mask,  and  that  her  head  was  transformed  into  the  head 
of  a  dog.  Ideas  of  persecution  supervened.  It  became 
difficult  to  close  the  mouth,  and  the  voice  was  strongly 
nasal.  The  swelling  at  last  receded,  and  at  the  same  time 
the  mental  condition  improved. 

The  following  case  is  briefly  summarized  from  my  notes  : 
Mrs.  G.  C.  at  the  age  of  forty-six  became  aftected  for  the 
first  time  with  acute  mania.  She  had  led  a  rather  loose  in- 
temperate life.  She  was  rambling  and  incoherent  in  her  talk. 
She  declared  that  people  were  conspiring  to  cheat  her  out 
of  a  large  fortune.  Sensation  was  acute,  speech  rapid  and 
voluble.  Her  attack  of  excitement  passed  off  in  a  few  weeks, 
and  some  months  later  she  suffered  from  mental  depression, 
which  seemed  to  be  associated  with  indigestion  and  con- 
stipation. She  then  reacted  between  the  two  extremes  of 
maniacal   excitement   and   depression   for   eighteen   months, 


378  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

after  which  evidence  of  myxcedema  appeared.  At  this  time 
she  complained  a  good  deal  of  headache  ;  she  got  tired  readily 
when  walking.  Her  sight  failed,  and  she  became  more  de- 
pressed and  melancholy.  Two  months  later  she  was  seized 
with  a  peculiar  fit,  for  she  seemed  to  faint,  and  after  coming 
to,  she  vomited  a  little,  and  rifted  up  wind.  These  fits  were 
repeated,  and  after  them  she  suffered  from  most  terrifying 
hallucinations  of  sight  and  taste,  and  died  in  a  few  weeks. 
Post-mortem  examination  revealed  a  round-celled  sarcoma  of 
the  left  tempero-sphenoidal  lobe. 

A  case  of  myxcedema,  on  recovery,  gave  from  memory  the 
following  account  of  her  case  :  '  I  was  in  the  infirmary  a 
week,  and  then  in  the  asylum,  but  knew  nothing  about  it 
till  I  woke  up,  shouting,  "  Prepare  to  meet  your  God  !" 
My  voice  seemed  like  a  trumpet,  it  was  so  loud,  and  it 
sounded  strange.  I  looked  out  of  the  window  and  thought 
it  was  a  new  world  ;  it  was  just  lovely.  The  next  time  I 
came  to  myself  was  in  the  train,  being  taken  to  another 
asylum.  I  thought  the  engine  was  always  howling,  "  Jennie 
Craig  !  Jennie  Craig  !"  I  thought  I  was  being  taken  to 
some  river  to  be  drowned.'  There  were  evidently  blanks 
in  her  memory,  if  not  in  her  consciousness.  Some  time 
later  she  says  :  '  I  thought  the  Lord  was  coming,  and  there 
was  a  lot  of  people  gathered  together,  and  in  the  crowd  I 
saw  a  man  whom  I  knew,  and  he  was  praying  to  the  Lord 
to  stay  His  hand,  for  the  world  was  not  all  converted.  I 
had  a  bag  in  my  hand,  and  the  devil  came  and  tempted 
me  to  give  it  to  him.' 

The  prognosis  of  this  form  of  insanity,  thanks  to  the 
discovery  of  thyroid  treatment,  is  now  most  hopeful,  if  there 
are  no  grave  organic  complications,  as  in  the  case  of  tumour 
of  the  brain  already  described.  After  recovery  is  complete, 
the  treatment  requires  to  be  still  pursued,  else  relapse  will 
take  place. 

Phthisis  and  Insanity. 

To  Dr.  Clouston  we  owe  the  term  '  phthisical  insanity,'  and 
his  description  of  the  mental  symptoms  associated  with 
phthisis  was   so   striking,   and    seemed  to   be   so   frequently 


PHTHISIS  AND  INSANITY  379 

justified  in  the  experience  of  others,  that  for  some  time  the 
term  'phthisical  insanity'  was  in  common  use.  In  his  latest 
writings  on  the  subject,  Dr.  Clouston  still  strongly  asserts 
the  intimate  relations  of  phthisis  and  insanity,  and  still 
recognises  the  existence  of  a  specific  form  of  insanity  under 
the  designation  phthisical.  Undoubtedly  a  good  deal  can 
be  said  for  his  view  that,  as  phthisis  is  more  common  among 
the  insane,  and  the  scrofulous  habit  is  most  prevalent  in  the 
idiot  class,  there  may  be  some  intimate  relation — a  twin 
sistership,  so  to  speak,  of  the  two.  When  Clouston,  Schroeder, 
Van  der  Kolk,  and  others,  first  directed  attention  to  the 
subject,  phthisis  was  a  much  more  frequent  disease  in  asylums 
than  it  is  to-day,  and  the  material  for  clinical  study  was 
therefore  much  larger  in  amount.  Whether  as  a  result  of 
improved  hygienic  conditions,  or  a  change  in  the  type  of 
disease,  insanity  and  phthisis  are  not  nearly  so  frequently 
associated,  nor  is  morbid  suspicion  so  frequent  a  symptom  as 
might  be  expected.  This  used  to  be  regarded  as  the  essential 
symptom  in  the  insanity  of  phthisis,  but  as  Clouston  points  ^ 
out,  it  is  also  a  symptom  where  ansemia  is  a  marked  condi- 
tion, and  it  certainly  is  in  phthisis.  It  is  not  surprising  that 
wherever  there  is  morbid  suspicion  there  should  often  be 
delusions  of  poisoning  and  refusal  of  food.  '  We  have  in 
cases  of  phthisis  seen  in  asylums  depressed  vitality,  depressed 
reflexes,  often  negative  pulmonary  symptoms,  and  a  low- 
pressure  circulation  ;  but  tubercular  disease  manifests  itself 
in  a  variety  of  ways.  It  is  a  fact  that  phthisis  in  asylums 
is  often  unassociated  with  symptoms,  and  owing  to  the 
mental  state  and  the  deficient  nervous  energy,  auscultatory 
phenomena  are  feebly  produced.  It  is  quite  common  to 
have  phthisis  without  cough  or  spit,  and  without  any  increase 
of  temperature  during  at  least  the  first  half  of  the  disease, 
and  this  is  the  time  when  we  depend  on  percussion  alone 
for  a  provisional  diagnosis,  when  loss  of  weight  directs  atten- 
tion to  the  chest.  Some  cases  show  no  evidence  whatever  of 
gastro  -  intestinal  affection,  while  others  present  abdominal 
symptoms  with  very  little  coincident  changes  in  the  lungs. 

Another    group    presents    gastric    symptoms    as    the   only 
prominent   feature   of  the   disease  ;  while   a  fourth  is  tuber- 


38o  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

cular  in  the  joints  and  in  the  subcutaneous  tissues.  In  a 
series  of  cases  of  the  last  class  I  have  seen  the  very  opposite 
mental  conditions  :  in  the  one  extreme,  mental  depression, 
fear  and  suspicion  ;  in  the  other,  exaltation,  with  delusions 
of  identity,  a  feeling  and  expression  of  well-being,  and  no 
evidence  whatever  of  any  physical  discomfort. 

According  to  Clouston,  cases  of  epilepsy  with  insanity 
superadded  to  phthisis  occur  in  a  greater  proportion  than 
the  appearance  of  phthisis  with  most  other  forms  of  insanity. 
This  has  not  been  my  experience.  He  has  observed  in 
general  paralysis  that  melancholic  symptoms  are  often 
associated  with  pulmonar}-  consumption.  One  very  im- 
portant point  is  the  question  of  diagnosis.  When  a  patient, 
gaunt  of  aspect,  round-shouldered,  with  pale  or  sallow  com- 
plexion, and  rather  sunken  cheeks,  gives  vent  to  suspicion  of 
poisoning,  and  refuses  food,  one  may  be  inclined  to  suspect 
that  here  is  a  case  that  will  show  signs  of  phthisical  insanity, 
although  as  yet  there  are  no  physical  signs  of  tubercular 
disease.  Undoubtedly,  cases  of  neurotic  type,  lean,  wretchedly 
thin,  and  emaciated,  may  be  mistaken  for  phthisical  cases, 
when  the  anaemia  and  the  malnutrition  are  really  symptoms 
of  cardiac  diseases,  if  the  diagnosis  is  made  from  the  symptoms 
rather  than  from  the  physical  signs. 

Clouston  frankly  admits  that  in  some  of  his  cases  which  re- 
covered mentall}'  there  may  have  been  a  mistake  made  in 
the  diagnosis ;  but  he  observes  that  it  must  yet  be  claimed 
that  it  is  so  entirely  distinct  that  it  is  not  liable  to  be  con- 
founded with  insanity  non-phthisical,  accompanied  by 
ansemia,  or  excited  by  syphilis,  or  alcohol,  or  with  ordinary 
idiopathic  hereditary  delusional  insanity.  With  this  state- 
ment I  so  far  agree,  that  I  have  seen  such  cases  as  he 
describes ;  but  I  have  also  seen  phthisical  cases  of  an 
opposite  mental  type.  I .  have,  moreover,  to  admit  that 
mistakes  have  been  made  in  my  own  practice  in  the  diagnosis 
of  this  disease,  simply  because  from  the  mental  symptoms, 
as  given  by  Clouston,  I  attempted  a  diagnosis  before  there 
were  an}-  physical  signs  to  justify  it. 

There  is  no  more  common  symptom  of  insanity  than 
morbid  suspicion,  and  when  in  the  trail  of  this  comes  refusal 


POST-FEBRILE  INSANITY  381 


of  food,  it  is  but  a  natural  logical  result  in  a  diseased  mind. 
Add  to  these  anaemia  and  loss  of  weight;  and  if  these  are 
taken  together  as  evidence  of  phthisical  insanity,  there  will 
often  be  cases  of  mistaken  diagnosis,  unless  beforehand  a 
careful  physical  examination  has  revealed  the  beginnings  of 
tubercular  disease.  The  treatment  of  patients  suffering  from 
phthisis  and  insanity  is  now  more  hopeful  than  formerly, 
and  it  is  not  necessary  to  give  directions  here  for  the  treat- 
ment of  a  disease  which  is  so  well  known  in  general  practice. 
With  plenty  of  fresh  air,  a  careful  and  suitable  dietary,  a 
dry  warm  climate,  and  the  usual  therapeutic  measures 
indicated  in  this  disease,  according  to  site  and  symptoms,  a 
great  deal  more  can  be  done  than  formerly. 

Post-Febrile  Insanity. 

This  was  a  term  applied  by  the  late  Dr.  Skae  to  attacks 
of  insanity  following  immediately  on  the  appearance  of 
zymotic  disease,  or  as  a  result  of  exhaustion  therefrom. 
Delirium  is  known  to  be  a  frequent  accompaniment  of 
fevers.  With  high  temperature,  a  condition  of  the  blood  is 
induced  which,  along  with  the  toxic  state  characterizing  the 
particular  fever  present,  favours  delirium  with  hallucinations, 
sometimes  a  very  acute  maniacal  delirium  requiring  more 
attention  than  the  ordinary  febrile  symptoms  themselves. 
The  subject  of  insanity  in  relation  to  fever  has  attracted 
considerable  attention  for  many  years.  Post-febrile  insanity 
may  follow  zymotic  and  non-zymotic  diseases.  It  has  been 
known  to  be  associated  with  scarlet  fever,  typhus,  small- 
pox, typhoid,  erysipelas,  and  rheumatic  fever.  The  insanity 
may  appear  with  the  first  appearance  of  the  fever  itself,  in 
the  form  of  a  maniacal  attack.  Bristowe  and  Murchison 
have  observed  cases  of  mania  at  the  period  of  febrile 
invasion.  It  must  not  be  supposed  that  the  severity  of  the 
mental  symptoms  is  an  indication  of  the  gravity  of  the 
febrile  process.  In  many  cases  it  is  quite  the  other  way,  the 
mental  excitement  being  due  to  a  nervous  susceptibility 
peculiar  to  the  patient  himself.  According  to  Nasse,  post- 
febrile insanity  may  appear  at  three  different  epochs  :  First, 
as  the  immediate  result  of  the  fever  itself ;  second,  as  a  pro- 


382  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

longation  of  the  delirium  when  the  fever  has  subsided ; 
third,  during  the  period  of  convalescence  from  fever.  To 
sum  up,  therefore  :  Insanity  associated  with  febrile  conditions 
may  be  maniacal  and  delirious  in  the  early  stages  of  the 
fever.  As  the  fever  subsides,  a  more  persistent  maniacal 
state  may  supervene,  or  during  convalescence  it  may  be 
noted  that  the  patient  is  not  recovering  his  mental  vigour  ; 
that  there  is  apathy,  indifference,  mental  torpor,  enfeebled 
memory,  and  a  want  of  consciousness  of  his  real  position 
and  surroundings.  In  the  last  form  the  prognosis  is  not  so 
good  ;  but  in  the  case  of  patients  affected  at  an  earlier  stage, 
so  far  as  my  experience  goes,  the  results  have  been  satisfac- 
tory. The  following,  however,  was  an  exception.  It  was  a 
case  of  acute  maniacal  delirium  coming  on  immediately  after 
the  onset  of  an  attack  of  t}'phoid  fever ;  the  patient  showed 
great  irritability  of  temper  before  the  onset  of  the  fever,  and 
■on  the  third  night  was  quite  delirious  and  excited,  singing, 
shouting,  swearing,  and  cursing  her  friends  and  relations. 
Once  she  attempted  to  jump  out  of  a  window,  and  had  to 
be  restrained.  In  her  case  there  was  a  family  history  of 
insanity,  and  the  sister  was  delirious  for  two  weeks  during 
an  attack  of  fever.  This  patient  ultimate^  degenerated  into 
a  state  of  dementia,  being  dirty  in  her  habits,  neglectful  of 
her  appearance,  pulling  her  clothes  all  over  her  knees, 
refusing  to  speak,  and  in  other  respects  being  silly  and 
childish.  The  bad  effects  of  the  exanthemata  are  well  seen 
in  early  life  in  children  hitherto  inteUigent  and  apt  at  school, 
who  thereafter  exhibit  as  after-effects  of  exanthemata  a  slow- 
ness of  comprehension,  stupidity,  and  an  inability  to  acquire 
further  education.  There  are  many  such  cases  to  be  found, 
and  they  sometimes  succumb  afterwards  to  an  outbreak 
of  mental  excitement,  and  require  to  be  sent  to  asylums. 
Wherever  there  is  a  nervous  history  in  a  family,  the  care  of 
patients  suffering  from  any  of  the  exanthemata  should  be  a 
matter  of  serious  concern. 

Raynaud's  Disease. 

Raynaud's  disease  in  relation  to  insanity  is  perhaps  not  so 
frequently  met  with  as  might  be  expected,  though  cases  have 


RAYNAUD'S  DISEASE  AND  INSANITY  383 

been  cited,  and  the  very  neurotic  and  vaso-motor  character  of 
the  disease  places  it  in  very  close  relation  to  brain  affections. 
Not  only  so,  but  it  is  also  intimately  associated  with  mental 
changes,  emotional  disturbances,  and  disorders  of  menstrua- 
tion either  as  a  forerunner  or  a  sequel.  The  fact  also  that 
it  is  not  uncommon  in  children  gives  further  emphasis  to 
its  neurotic  character,  as  also  its  appearance  in  the  mildest 
forms  in  patients  suffering  from  mental  disease,  I  have  on 
several  occasions  noticed  the  coldness  and  pallor  of  the 
'dead  finger  stage,'  especially  in  women.  Dr.  Macpherson 
has  described  a  very  remarkable  case  occurring  in  a  young 
girl  during  adolescence  (Journal  of  Mental  Science,  April, 
i88g).  The  hereditary  tendency  to  insanity  was  very  strong. 
The  onset  of  the  attack  was  characterized  by  mental  de- 
pression and  suicidal  impulses.  She  soon  passed  into  a 
state  of  mental  excitement,  with  grandiose  delusions. 
Menstruation  had  for  many  months  been  irregular.  The 
temperature  was  g8°  Fahr,,  her  pulse  was  70,  and  the  organs 
of  the  chest  and  abdomen  were  apparently  healthy.  Four 
days  after  coming  to  the  asylum,  she  had  a  cold  and  pinched 
appearance;  the  hands,  and  the  arms  up  to  the  elbow,  had 
a  mottled  blue  and  red  colour.  Temperature,  98°  Fahr. 
She  now  passed  into  a  state  of  stupor,  but  was  restless, 
probably  from  discomfort,  if  not  from  pain.  Then  her  feet, 
and  her  legs  up  to  the  knee,  presented  the  same  phenomena. 
Later  the  skin  assumed  a  brick-red,  congested  appearance. 
On  the  tenth  day  of  asylum  residence,  there  were  noticed 
purple-black  spots  on  the  tips  of  the  first  three  toes  of  the 
right  foot.  Temperature  98°  Fahr.  The  patient  was  now 
unconscious,  with  stertorous  breathing  ;  the  remaining  toes 
of  the  right  foot  and  those  of  the  left  became  affected,  and 
the  disease  extended.  The  patient  required  to  be  artificially 
fed.  The  congestive  colour  in  all  the  limbs  passed  away, 
the  gangrene  sloughed,  the  patient's  bodily  health  improved, 
and  on  one  day  the  temperature  rose  to  100°.  Concomitant 
with  the  improvement  in  the  bodily  health  came  a  gradual 
return  of  the  acute  mania,  and  finally  she  recovered  men- 
tally, having  been  insane  fully  six  months.  The  chief 
treatment  was  warmth.      She  was  placed  in    a   room    the 


384  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

temperature  of  which  was  67''  Fahr.,  she  was  well  wrapped 
in  blankets,  the  arms  and  legs  were  encased  in  cotton-wool, 
and  she  was  surrounded  by  hot-water  bottles.  Internally 
she  was  liberally  supplied  with  hot  beef-tea  and  stimulants, 
in  addition  to  custard  diet. 


Rheumatism  and  Insanity. 

Rheumatism,  especially  rheumatic  fever,  is  sometimes 
associated  with  insanity.  The  experience  of  those  who  have 
had  much  to  do  with  mental  disease  is,  that  rheumatism 
presents  itself  as  an  accompaniment  or  as  the  precursor  of 
a  mental  attack.  This  is  particularly  noticed  in  connection 
with  outbreaks  of  chorea,  and  I  have  already  described  a 
case  in  the  chapter  on  the  Insanity  of  Puberty,  etc.,  where 
rheumatism,  chorea,  and  insanity  were  interchangeable.  As 
I  have  also  already  remarked,  rheumatic  affections  are  found 
in  the  insanity  of  lactation.  Dr.  Clouston  has  very  par- 
ticularly described  what  he  calls  rheumatic  insanity,  and 
in  1870  furnished  reports  of  two  cases  in  illustration  of 
this  disease.  Savage,  speaking  of  insanity  in  relation  to 
rheumatic  fever  as  a  post-febrile  state,  observes  that  he  has 
noticed  striking  moral  perversions  in  patients  after  recovery 
from  rheumatic  fever.  These  changes  in  the  moral  character 
of  the  individual  would  seem  to  imply  that  there  has  been  a 
mental  susceptibility — it  may  be  a  hereditary  mental  weak- 
ness— not  suspected  until  the  attack  of  rheumatic  fever  had 
spent  itself.  Clouston  groups  the  rheumatic  and  choreic 
insanities  as  one,  believing  that  there  is  a  close  connection 
between  chorea  and  rheumatism,  and  secondarily,  between 
these  and  insanity.  It  seems  very  natural  that  in  neurotic 
subjects  the  rheumatic  poison  should  select  the  nervous 
system  for  its  prey,  especially  the  motor  centres  ;  but  unless 
its  effects  are  very  severe,  or  there  is  mental  susceptibility, 
insanity  is  not  likely  to  supervene. 

Cerebral  rheumatism  has  been  described  b}'  Trousseau, 
in  one  case  appearing  in  a  drunkard,  and  in  another  in  a 
woman  who  had  been  insane.  He  distinguishes  six  forms 
of  cerebral  rheumatism  :    the   apoplectic,  the   delirious,  the 


RHEUMATISM  AND  INSANITY  385 

meningitic,  the  hydrocephalic,  the  convulsive,  and  the 
choreic ;  but  these  divisions  he  regards  as  somewhat  arbi- 
trary. He  did  not  regard  the  cerebral  phenomena  as  a 
consequence  of  metastasis,  but  as  generally  owing  to  some 
morbid  cerebral  predisposition,  such  as  previous  habits  of 
drunkenness  or  some  former  neurosis.  One  of  the  cases  which 
he  described  was  a  charwoman  who  had  been  addicted  to 
spirit-drinking.  Her  story  was  given  by  herself  as  follows  : 
On  the  Sunday  previous  to  admission  she  had,  after  doing  her 
work,  gone  to  Notre  Dame  to  Mass.  She  could  not  follow  the 
service  as  usual,  and  did  not  understand  it,  and  at  the  same 
time  she  felt  an  acute  pain  in  her  right  shoulder.  After 
church  she  went  to  a  house  to  do  some  work  as  charwoman, 
although  she  felt  queer.  She  did  part  of  her  work  in  a 
mechanical  manner,  and  then  sat  down  in  a  stupid  state  in 
a  dark  corner  of  the  kitchen,  where  she  remained  silent  and 
motionless.  She  got  into  bed,  slept  well,  and  woke  the  next 
morning  speechless.  She  was  evidently  distinctly  aphasic,  and 
unable  to  express  her  wishes  to  her  husband.  By-and-by, 
when  she  was  able  to  speak,  she  spoke  in  a  spurting  manner. 
Owing  to  the  threat  of  one  of  the  lodgers  to  shoot  her  husband, 
she  became  so  frightened  that  she  was  mad  with  fear,  and 
had  to  be  taken  to  the  Salpetriere  three  days  afterwards,  re- 
maining there  for  thirteen  months  in  a  state  of  fierce  mania. 
In  this  case  the  most  remarkable  circumstance  was  an 
irresistible  tendency  to  doze,  exactly  as  if  she  had  been 
struck  with  apoplexy.  She  would  begin  a  sentence  well,  but 
by  degrees  speak  less  and  less  intelligibly  and  rapidly,  then 
stop  and  drop  off  to  sleep.  *  When  shaken  sharply,  she  would 
wake  up,  look  around  with  wondering  eyes,  answer  questions 
clearly,  but  soon  doze  off  again. 

As  Trousseau  has  observed,  articular  rheumatism  has  no 
great  tendency  to  develop  cerebral  manifestations.  However 
intense  the  fever  and  the  pain  may  be,  this  complaint  does 
not  usually  give  rise  to  toxic  phenomena,  to  delirium,  or  to 
hallucinations  :  the  intellect  is  ■  unimpaired  ;  and  yet  some 
cases  do  occur  in  which  the  rheumatism  is  complicated  with 
brain  symptoms  occurring  independently  of  the  intensity  of 
the  disease  and  its  gravity,  as  well  as  of  its  extent.     In  such 

25 


386  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

cases  there  must   be  an  acquired  or   inherited  nervous  or 
mental  predisposition, 

A  very  interesting  case,  all  the  more  interesting  because 
of  its  exceptional  features,  is  described  by  Dr.  Clouston.  It 
came  on  in  a  woman  as  the  result  of  poverty,  hard  work, 
and  lactation.  This  case  shows  the  relations  of  insanity, 
not  only  with  rheumatism,  but  with  chorea.  In  it  rheumatism, 
in  the  form  of  rheumatic  pains  with  slight  feverishness,  were 
the  first  symptoms  ;  then  she  passed  into  a  state  of  mental 
excitement,  the  rheumatic  symptoms  apparently  disappearing. 
Choreic  movements  were  associated  with  the  mental  excite- 
ment ;  paraplegia  followed,  and  thereafter  disappeared  ;  but 
the  chorea  appears  to  have  continued  for  some  time  after. 
Hallucinations  of  sight  and  touch  were  present  in  this  case. 
Chorea,  in  cases  of  insanity  especially,  ma}'  be  idea-motor, 
or  occur  as  a  result  of  nervous  discharges  from  the  lower 
reflex  centres.  From  what  has  been  seen  of  the  relations  of 
rheumatism  and  insanity,  it  is  evident  that  chorea  is  not 
necessarily  an  accompaniment  ;  but  when  it  is  also  present, 
we  find  in  some  cases  the  mental  symptoms  have  a  re- 
semblance to  the  motor,  being  often  explosive,  inconsequent, 
erratic,  and  ill  expressed.  Chorea  is  not  necessaril}^  limited 
to  earl}'  youth,  for  Clouston's  case  was  that  of  a  married 
woman,  and  cases  of  post-hemiplegic  character  are  not  un- 
common. It  is  probable,  however,  that  when  rheumatism  is 
associated  with  insanity  in  later  life,  chorea  is  more  rarely 
manifested,  the  neurotic  inheritance  and  susceptibility  being 
less  marked. 

Sunstroke  and  Insanity. 

Not  much  is  known  of  this  subject,  for  the  reason  that 
sunstroke  is  an  infrequent  accident  in  this  country,  and  is 
more  often  likely  to  affect  children,  especially  infants  in 
arms,  than  grown-up  people.  It  is  unnecessary  to  go  into 
the  distinction  between  coup  de  soleil  and  coup  de  chaleur, 
commonly  called  heat-stroke.  It  is  well  to  bear  in  mind 
that  cases  of  idiocy  have  been  traced  to  sunstroke,  often  as 
the  result  of  carelessness  on  the  part  of  the  nurse,  exposing 
the  head  and   face  to  the  rays  of  the  sun.      In  the  case  of 


UTERINE  DISEASE  AND  INSANITY  387 

patients  becoming  insane  who  have  Hved  in  foreign  countries 
— soldiers,  sailors,  and  others — it  is  a  frequent  inference 
rather  than  a  correct  statement  of  fact  to  say  in  many  that 
the  patient  suffered  from  sunstroke.  In  the  Red  Sea  it  is 
not  uncommon  to  suffer  from  the  intense  heat,  and  I  had 
one  case  of  an  engineer  recently  under  care,  a  full-blooded 
man,  who  suffered  so  much  in  this  way  that  he  became 
insane. 

Uterine  Disease  and  Insanity. 

When  so  much  of  mental  disease  has  been  attributed  in 
greater  or  lesser  degree  to  physical  disease,  it  would  be 
surprising  indeed  if  the  uterus  escaped  from  such  a  classifi- 
cation. Ranged  on  one  side  are  those  who  believe  in  the 
undoubted  influence  of  the  uterus  and  its  appendages  on 
sexual  emotion  and  mental  processes  generally,  and  on  the 
other  side  those  who  regard  not  only  uterine  disease,  but  all 
ph3^sical  diseases,  as  accidents  in  no  way,  or  only  in  a  slight 
degree,  correlated  with  mental  disease.  In  the  United  States 
a  great  deal  more  has  been  done  by  women  doctors  in  asylums 
to  investigate  the  truth  of  the  matter  than  has  been  done 
in  this  country,  and  one  must  confess  to  a  satisfaction  in 
knowing  that  a  difficult  and  delicate  subject  has  been  so 
thoroughly  well  handled  by  medical  members  of  the  female 
sex  themselves.  We  may  confess,  however,  to  a  certain 
scepticism  regarding  the  statistics  which  have  been  adduced 
to  prove  that  uterine  disorders  are  an  important,  and  in 
many  cases  a  critical,  factor  in  the  production  of  insanity. 

Dr.  Wiglesworth  has  entered  into  this  matter  with  his 
usual  thoroughness,  and  examined  a  number  of  cases,  post- 
mortem as  well  as  during  life.  From  the  study  of  these 
cases,  the  conclusion  at  which  he  arrives  is  that  uterine 
abnormalities  are  of  more  frequent  occurrence  among  the 
insane  than  is  naturally  supposed. 

Dr.  Wiglesworth  cannot  help  entertaining  the  opinion 
that  instances  must  occasionally  occur  in  which  the  non- 
recognition  of  uterine  disease,  at  an  early  stage,  must 
result  in  a  case  at  one  time  evidently  curable  passing  into 
a    state  of  chronic   insanity.     It    is    quite   conceivable   that 

25—2 


388  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

cures  have  in  this  way  been  missed,  and  it  is  eminently 
desirable  that  something  should  be  done  to  diminish  this 
possibility.  Considering  that  so  much  attention  has  been 
given  to  this  subject  outside  asylums,  that  so  many  women 
are  continually  being  ministered  to  by  specialists  in  women's 
diseases,  and  that  with  all,  a  number  of  cases  of  uterine 
diseases  come  to  asylums,  it  is  questionable  if  much  good 
could  be  done  in  a  great  many  of  these  cases,  which  must 
necessarily  be  chronic  by  the  time  asylum  treatment  is 
thought  of.  A  utero-hypochondria  is  probably  a  frequent 
mental  condition  in  the  patients  who  seek  relief  from  gynae- 
cologists, and  it  might  be  much  better  for  some  of  them 
if  more  rigorous  mental  treatment  were  substituted,  and 
the  hypochondria  and  hysteria  received  less  sympathy  and 
indulgence. 

Undoubtedly  rtiany  delusions  of  insane  women  raise  the 
question  whether  there  may  not  be  some  partial  explanation 
at  least  to  be  found  in  the  sexual  organs.  In  some  hysterical 
cases  there  may  be  delusions  entertained  by  these  patients 
that  they  have  given  birth  to  rats  or  mice,  or  other  creatures  ; 
and  in  some  young  girls,  not  necessarily  hysterical,  on  the 
suggestion  of  hallucinations,  or  owing  to  nervous  or  other 
affections  of  the  sexual  organs,  the  idea  of  maternity  becomes 
fixed,  the  patient  declaring  that  she  has  given  birth  to  a 
child  or  children.  One  of  my  cases,  a  girl  suffering  from 
post-influenzal  insanity,  is  positive  that  she  has  given  birth 
to  four  children  at  one  time,  and  that  we  have  taken  away 
and  destroyed  them.  She  is  subject  to  hallucinations  of 
hearing,  menstruates  regularly  and  normally,  and  being 
unmarried,  we  have  inferred,  without  vaginal'  examination, 
that  there  is  no  organic  disease  of  the  sexual  system. 

The  relation  of  uterine  disease  to  insanity  is  more  frequently 
noticed  in  married  women,  and  especially  at  the  climacteric. 
The  disorders  of  the  menopause,  the  climax  it  may  be  of 
disorders  occurring  during  the  child-bearing  period  of  life, 
are  more  likely  now  to  be  suggestive  to  women,  in  the 
nervous  susceptible  condition  associated  in  many  cases  with 
'  the  change  of  life.'  Chronic  metritis,  uterine  displacements, 
fibroid  tumours,  and  other  conditions,  are  more  likely  then, 


UTERINE  DISEASE  AND  INSANITY  389 

to  give  rise  to  sexual  delusions.  Be  that  as  it  may,  I  have 
found  sexual  delusions  most  common  in  women  verging  on 
forty,  and  from  forty  to  fifty-five  years  of  age  ;  delusions  of 
improper  intercourse,  of  being  chloroformed  and  violated, 
are  by  no  means  uncommon.  Delusions  of  pregnancy  and 
of  having  given  birth  to  children,  or  of  induced  labour  for 
malevolent  ends,  are  quite  an  every-day  experience  in 
asylums. 

The  wildest  animal  ferocity  that  I  have  ever  seen,  was  in 
a  woman  with  a  strain  of  Kaffir  blood  in  her  composition, 
whose  homicidal  fury  was  something  terrible,  in  her  paroxysms 
of  excitement  over  the  alleged  abstraction  of  her  children  by 
the  doctor  when  she  was  asleep.  The  delusions  came  in  the 
morning  on  waking,  without  any  regard  for  the  physiological 
time  limit  of  gestation,  without  any  reasoning  process  to 
account  for  the  possibility  of  her  conception  of  children  at 
intervals  of  a  few  days,  or  their  full-time  development  in  so 
short  a  period.  In  her  case  there  was  a  uterine  fibroid. 
Another  case  under  treatment  in  the  hospital,  a  patient 
suffering  from  chronic  phthisis  and  uterine  disease,  has  the 
delusion  that  she  has  been  enceinte  for  three  years.  There 
are  no  outward  signs  that  could  by  any  stretch  of  the 
imagination  give  a  suggestion  for  this  delusion.  When 
asked  how  soon  she  expects  the  birth  of  the  child,  she 
replies,  '  When  the  good  Lord  pleases.' 

Ovarian  or  old  maid's  insanity  was  a  name  given  by  the 
late  Dr.  Skae,  of  Morningside,  to  a  form  which  is  very  rare — 
I  have  only  seen  one  in  a  thousand  cases  of  female  insanity 
— but  which  so  far  as  the  mental  symptoms  go  is  very 
characteristic.  There  may  be  reasonable  doubts  as  to  the 
relation  of  ovarian  disease  to  this  form  of  insanity;  but  the 
mental  symptoms,  whatever  their  explanation,  are  stereotyped 
for  all  cases.  The  patient  believes  she  is  married,  and  the 
unhappy  victim  of  this  delusion  is  a  clergyman.  We  know 
how  often  the  clergyman  is  worshipped  by  many  of  the 
female  members  of  his  congregation  ;  but  when  adoration 
takes  the  form  of  insanity,  the  case  is  rather  unpleasant  for 
the  clergyman,  especially  if  he  is  a  married  man.  The 
patient  I  have  referred  to  made  the  life  of  her  clergyman,  a 


390  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

married  man,  most  unbearable.  She  declared  she  was  his 
wife,  in  the  face  of  the  true  wife,  and  not  until  she  was 
removed  to  the  asylum  had  he  any  peace  whatever.  There 
she  wrote  him  letters  daily,  and  was  in  no  wise  embittered 
against  him  because  she  had  been  sent  to  the  asylum.  She 
was  too  weak-minded  for  that,  not  sufficiently  self-assertive, 
though  she  did  annoy  him  when  outside.  Her  letters  were 
irrelevant,  rambling,  inconsequent.  She  was  otherwise  docile, 
gentle,  and  adaptable.  This  form  of  insanity  is  most  hope- 
less. 


CHAPTER  XVIII. 

MENTAL  DEVELOPMENT  RETARDED  OR  IMPAIRED  AS 
DISTINGUISHED  FROM  IMBECILITY  AND  IDIOCY— THE 
BACKWARD  AND  FEEBLE-MINDED. 

No  ideal  standard — All  children  not  on  the  same  plane  of  competence — 
The  data  of  feeble-mindedness — Physical  stigmata— Abnormal  de- 
velopment— Abnormal  nerve  signs — Malnutrition  and  ill  health  — 
Defects  of  sensation — The  examination  of  the  mental  condition — 
Attention — Observation — Time  -  reaction — Memory — Speech — Moral 
and  emotional  character — Sleep. 

The  ideal  of  mental  perfection  is  rarely  if  ever  attained. 
We  are  accustomed  to  the  truism  that  '  no  man  is  perfect.' 
Intellectual  ability,  emotional  stability,  moral  sensitiveness, 
volitional  control,  have  no  rigid  standard  of  perfection.  The 
whole  man  is  judged  with  all  his  parts  and  attributes  ap- 
praised together,  and  we  estimate  accordingly.  At  the 
opposite  pole — and  the  range  between  the  two  is  wide  and 
unlimited — we  get  more  and  more  negative  results  the  nearer 
.we  come  to  it. 

It  has  been  customary  to  divide  mankind  into  four  classes. 
Beginning  at  what  may  be  called  the  lowest  grade  or  the 
negative  pole,  is  the  idiot,  further  away  the  imbecile,  still 
further  the  lunatic,  and  last  and  largest  class  of  all  the  normal 
man.  This  last  class,  whether  studied  in  the  early  or  latter 
stages  of  development  or  at  full  maturity,  presents  a  variety 
of  mental  constitution  and  character  as  numerous  as  the 
individuals  themselves.  They  are  not  all  on  the  same  plane 
of  competence,  not  all  equally  gifted,  nor  developing  and 
maturing  at  the  same  pace  nor  in  the  same  directions.  Even 
in  the  idiot  and  the  imbecile  there  are  manifold  diversities 
and  degrees  of  intelligence. 


392  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

In  our  public  schools  there  are  standard  classes  for  average 
boys,  and  removes  for  the  delicate  and  backward.  The 
careful  individualizing  of  pupils  has  clearly  brought  out  the 
fact,  never  so  clearly  realized  before,  that  there  are  differences 
in  boys  and  girls  which  the  machinery  of  the  old- school 
regime  did  not  allow  for.  Experience  teaches  us  that  some 
so-called  stupid,  incompetent  boys  have  been  merely  slow 
boys.  Sir  Walter  Scott,  James  Watt,  and  Syme  were  pro- 
nounced slow  boys  ;  probably  the  arbitrary  and  sometimes 
tyrannical  schoolmaster  of  the  past  called  them  something 
worse.  A  great  deal  of  attention  has  lately  been  given  to 
the  subject,  and  we  owe  much  to  Dr.  Francis  Warner,  and 
the  committee  of  which  he  has  been  so  active  a  member,  for 
the  very  exhaustive  investigation  which  has  been  made 
in  this  matter.  There  can  be  no  question  whatever  that 
it  is  one  of  the  utmost  importance  in  the  interest  of  future 
generations ;  and  to  the  medical  profession  belongs  the 
responsibility  of  studying  the  matter,  and  advising  as  to 
the  mental  development  and  education  of  young  people. 

The  data  of  feeble-mindedness,  backwardness,  imbecility, 
and  idiocy  have  not  till  quite  recently  been  established  with 
anything  like  an  approach  to  precision.  Hitherto  it  has 
been  much  more  easy  for  a  medical  man  to  say  that  a  boy 
is  an  idiot  than  to  adduce  reasons  for  this  belief;  and  as 
to  the  backward  and  feeble-minded,  the  recognition  of  such 
cases,  and  the  data  on  which  this  recognition  is  founded, 
have  received  very  little  attention.  There  is  now  before 
us,  thanks  to  Warner,  Langdon  Down,  Shuttleworth, 
Fletcher  Beach,  and  others,  a  well  -  devised  system  of 
classical  inquiry  for  all  cases,  whether  of  limited  or  grave 
defect,  which  must  facilitate  classification  and  educational 
treatment.  It  will  do  more,  for  these  physical  and  nervous 
signs  are  just  such  tangible,  palpable  facts  as  a  judge  and 
jur}'  can  appreciate,  and  they  ought  to  be  regarded  as  cumu- 
lative evidence  of  considerable  importance. 

The  committee  referred  to  was  appointed  jointly  b}-  the 
British  Association,  the  British  Medical  Association,  the 
Charity  Organization  Society,  the  Royal  Statistical  Society, 
the  Sanitary  Institute,  and  consisted  also  of  foreign  repre- 


THE  BACKWARD  AND  FEEBLE-MINDED  393 

sentatives.  In  the  words  of  the  preface  to  its  report :  '  The 
object  of  the  committee  in  undertaking  this  investigation  of 
the  mental  and  physical  condition  of  childhood  was  to  furnish 
a  reliable  statement  of  existing  conditions  found  among  the 
pupils  attending  public  elementary  and  other  schools,  and 
thus  to  establish  a  scientific  basis  for  the  study  of  the  require- 
ments of  child  life.'  Altogether,  separately  or  in  combination, 
the  public  bodies  referred  to  have  presented  statistics  relative 
to  100,000  children. 

It  was  found  that  '  among  2,961  Jewish  children  in  day- 
schools,  uniformality  of  development  was  very  marked,  there 
being  only  7*5  per  cent,  of  deviations  from  the  normal,  and 
all  points  in  nutrition,  nerve  action,  and  mental  status 
appeared  niore  regular  among  them  than  in  English  children, 
in  whom  the  amount  of  deviation  from  the  normal  was 
ascertained  to  be  io'8  per  cent.'  This  latter  fact  is  suffi- 
ciently striking  to  attract  attention,  and  cause  us  to  inquire, 
What  are  those  deviations  from  the  normal,  and  what  is 
their  pathognomonic  significance  ?  The  nomenclature  of  signs 
adopted  by  the  committee  as  a  basis  of  inquiry  is  so  exhaus- 
tive, and  comprises  so  many  minor  details,  that,  with  all 
respect  for  the  committee's  finding,  one  is  forced  to  assume 
that  many  of  the  signs  have  only  a  far-fetched  significance, 
and  are  contributory  particles  of  evidence  of  minor  or  doubt- 
ful value. 

With  this  reservation,  however,  we  are  bound  to  admit 
that  justified  by  results,  the  diagnosis  of  the  examiners,  who 
were  strangers  to  the  children,  was  amply  proved.  '  The 
teachers  almost  universally  acknowledged  that  the  dull 
children  had  been  selected  by  inspection,  and  very  few 
undetected  cases  were  subsequently  presented  by  them.' 
When  we  consider,  therefore,  that  from  this  list  is  excluded 
all  but  a  very  small  percentage  of  idiots,  imbeciles,  and 
epileptics,  the  importance  of  entering  somewhat  fully  into 
the  subject,  and  laying  down  rules  for  guidance  or  diagnosis, 
will  be  appreciated.  It  is  necessary  here  only  to  draw  atten- 
tion to  the  more  evident  signs,  and  those  having  undoubted 
meaning  in  relation  to  mental  capacity  and  development. 

The  committee  distinguished  four  groups  of  signs  observed 


394  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

in  the  study  of  children  :  (a)  Defects  in  development  of  the 
body  and  its  parts,  in  size,  form,  or  proportioning  of  parts ; 
{h)  abnormal  nerve  signs — certain  abnormal  actions,  move- 
ments, and  balances ;  (c)  low  nutrition,  as  indicated  by  the 
child  being  thin,  pale,  or  delicate  ;  {d)  mental  duhiess — the 
teacher's  report  as  to  mental  ability  was  added  to  the  record. 
This  classification  does  not  give  any  idea  of  the  elaborate 
detail  with  which  the  inquir}'  was  worked  out,  especially 
in  the  first  two  divisions  ;  but  the  inquiry  into  the  condition 
of  the  special  senses,  though  in  some  respects  adequate  in  its 
results,  is  not  so  as  regards  sensori-mental  relations,  and  the 
amount  or  character  of  the  mental  dulness  is  insufficiently 
expressed.  In  this  chapter  a  wider  range  of  individuals  must 
be  considered,  for  though  written  more  particularly  to  draw 
attention  to  the  backward  and  feeble-minded,  to  obtain  their 
due  recognition  and  treatment,  it  must  of  necessit}^  3-Pply 
also  to  the  diagnosis  of  idiocy  and  imbecility.  The  difference 
is  one  of  degree.  After  considering  the  more  important 
elements  of  the  classification  referred  to,  attention  must  be 
directed  to  the  amount  of  sensation  and  the  mental  condi- 
tion. These  are,  after  all,  the  fundamental  conditions, 
although  their  demonstration  is  not  always  so  apparent  nor 
so  striking  as  evidence  to  others. 

(a)  Defects  in  development  ma}'  be  gross  or  minor  in  kind. 
Minor  defects  are  apt  to  be  overlooked ;  some  are  not  recog- 
nised as  defects  at  all ;  some  even  are  asserted  to  be  evidence 
of  breeding.  Fine  breeding,  however,  may  go  perilously 
near  the  border-line,  and  be  classed  with  genius  and  de- 
generation. The  study  of  development — size,  proportion, 
and  symmetry — as  experience  shows,  is  one  which  is  full 
of  practical  interest.  This  is  quite  apart  from  any  evidence 
of  the  rate  of  growth,  of  which  probably  too  much  may  be 
made,  although  it  should  always  be  recorded,  i.e.,  the  height 
and  weight,  and  compared  with  the  standard  for  a  given  age. 
The  relation  of  the  size  of  the  cranium  to  the  size  of  the 
bod}'  generally  is  a  still  more  practical  question.  Naturally, 
this  is  regarded  as  of  great  importance,  and  even  in  children 
data  of  some  value  may  be  obtained  by  head  measurement 
and  a  study  of  the  cranial  conformation. 


THE  BACKWARD  AND  FEEBLE-MINDED  395 

The  following  is  the  standard  of  the  normal  in  a  well- 
developed  child  of  good  potentiality,  as  given  in  the  com- 
mittee's report ;  but  it  is  cautiously  added  that  it  is  probably 
too  high  if  deviations  therefrom  are  to  be  taken  as  pathological. 
It  is  certainly  unfortunate  for  practical  use  that  a  lower 
standard  was  not  aimed  at.  '  Head  circumference  at  nine 
m.onths  I7"5  inches,  at  twelve  months  19  inches,  at  seven 
years  20  to  21  inches.  After  three  years  of  age  ig  inches 
cranial  circumference  is  too  small.  In  this  investigation  no 
head  of  any  age  was  described  as  small  which  was  up  to 
a  circumference  of  20  inches.'  The  levels  when  taking  the 
circumference  of  the  head  are  the  frontal  eminences  anteriorly, 
and  the  occipital  protuberance  posteriorly. 

The  symmetry  of  the  head  is  regarded  as  a  point  of  some 
value  ;  but  we  have  no  precise  data  to  guide  us  regarding  the 
symmetry  of  the  average  cranium,  and  we  know  that  there 
are  often  found  post-mortem  cranial  formations  both  of  the 
base,  the  parietes,  and  the  dome  which  are  not  strictly 
symmetrical.  We  know  also  that  the  brain  is  a  most 
adaptable  organ,  and  asymmetrical  conditions  of  minor 
character  are  not  correlated  to  an}^  cerebral  defect  whatever. 
If  this  is  true  of  the  cranium  and  the  brain,  it  must  be  true 
of  many  of  the  asymmetrical  defects  of  less  important  parts, 
some  of  which  are  so  insignificant  as  to  be  unworthy  of 
notice.  Want  of  symmetry  of  the  cranium  may,  however, 
be  so  pronounced  as  to  necessitate  irregular  brain  develop- 
ment, or  it  may  be  the  result  of  brain  lesion.  In  cases 
of  rickets  it  is  well  always  to  examine  the  head  and  take 
measurements.     In  such  cases  the  head  is  often  large. 

The  size  and  form  of  the  head  give  indications  also,  but 
conclusions  should  be  drawn  guardedly,  unless  there  is  very 
obvious  malformation ;  and  one  should  judge  of  form, 
symmetry,  and  size  as  the  sum  total  of  the  whole  question,  for 
what  the  cranium  is  short  of  in  one  direction,  may  be  gained 
in  another,  and  within  limits  as  already  stated,  the  brain  is 
adaptable.  We  are  apt  to  arrive  at  erroneous  judgments  by 
merely  looking  at  a  man's  head.  The  so-called  science  of 
phrenology  had  much  to  answer  for,  because  it  taught  us  so 
much    about  bumps  that  were    mere    outside    excrescences, 


396  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

with  no  cerebral  counterpart.  A  bad  form  of  head  is  that 
which  shelves  back  at  a  sharp  angle  from  above  the  eyes,  and 
shelves  forward  also,  though  less  suddenly,  from  the  occipital 
protuberance.  This  is  frequently  seen  in  criminal  types, 
and  with  less  angular  acuteness  in  microcephales  (small- 
headed  idiots)  ;  but  though  it  is  the  extreme  deviation,  the 
angle  of  deviation  varies,  and  when  it  comes  nearer  the 
right  angle  in  front  and  the  obtuse  angle  behind,  a  very 
serious  mistake  may  be  made  in  gauging  the  potentiality  of 
the  child,  if  head  measurements  are  not  taken.  In  addition 
to  circumferential  measurement,  the  tape  should  be  taken 
from  mastoid  process  to  mastoid  over  the  summit.  The 
head  may  show  narrowness  of  forehead,  bosses  at  the  ossific 
centres  of  the  two  halves  of  the  frontal  bone,  over  the 
parietal  centres  and  elsewhere.  There  may  be  marked 
prominence  of  the  vertical  suture  joining  the  two  frontal 
bones,  a  linear  boss  which  is  very  ugly  and  gives  a  suggestion 
of  the  prow-shaped  forehead  of  the  scapho-cephalic  child. 
In  its  minor  degrees  it  is  often  associated  with  vaso-motor 
changes  externally,  and  the  skin  becomes  the  site  of  a  red 
blush  when  excited.  It  has  of  itself  no  mental  significance 
in  its  milder  forms,  but  is  a  sign  not  to  be  disregarded. 

The  two  extremes  in  head  measurements  are  the  hydro- 
cephalic (large  head)  and  the  microcephalic  (small  head). 
These  do  not  necessarily  mean  idiocy  or  imbecility,  and  the 
large  head  may  not  be  hydrocephalic,  though  that  is  the  rule, 
especially  if  the  frontal  bone  overhangs  very  perceptibly. 
The  committee  found  small  heads  more  common  among 
girls,  which  is  contrar}^  to  expectation  ;  but  they  came  to 
the  conclusion  that,  '  where  there  is  no  other  defect,  the 
mental  faculty  ma}-  be  average,  but  the  child  usually  remains 
thin  and  delicate.  Such  children  may  in  after-life  undertake 
good  work  and  do  it,  but  are  more  liable  than  others  to  ex- 
haustion, migraine,  and  breakdown  of  the  nervous  system.' 

It  was  found  that  the  dolichocephalic  (long-headed),  the 
oxycephalic — with  elevated  conical  head — and  others  with 
large  front  and  narrower  occiput,  did  not  afford  data  for 
precise  knowledge,  without  a  more  detailed  examination  and 
inquiry  than  was  possible  in  such  an  investigation.     It   may 


THE  BACKWARD  AND  FEEBLE-MINDED  397 

here  be  said  that  in  cases  of  rickets  there  is  ahvays  the 
possibihty  of  tubercular  disease  appearing,  and  mental  defect 
is  all  the  more  possible  in  such  cases.  One  cannot  expect 
the  same  quality  of  brain  in  these  cases,  and  if  there 
appears  to  be  brightness  and  intelligence,  it  may  be  mere 
precocity  or  morbid  scintillation,  with  diminishing  force  as 
time  goes  on. 

The  abnormalities  in  development  of  the  principal  features, 
the  eyes,  ears,  nose,  and  mouth,  have  been  studied  with 
much  care,  and  with  a  regard  for  every  detail.  It  is  well, 
therefore,  to  examine  these  as  a  part  of  the  system  of  inspec- 
tion of  children  believed  to  be  mentally  slow  or  defective. 

The  normal  eye  is  neither  unduly  prominent  or  depressed, 
the  palpebral  fissure  not  so  small  as  greatly  to  hide  the  eye- 
balls, the  transverse  axis  horizontal,  the  eyes  not  close 
together  or  far  apart,  and  the  eyebrows  separate  and  distinct, 
not  in  the  form  of  bristles,  and  not  meeting  in  the  middle 
line.  The  upper  eyelids  should  be  free  from  vascular  net- 
vvorks  or  diffuse  congestion.  From  this  normal  type  there 
are  many  deviations  not  in  themselves  significant,  and  of  no 
pathognomonic  value.  It  is  desirable,  however,  to  make  a 
note  of  all  such  deviations,  and  sum  up  the  total  afterwards. 
Thus,  for  example,  it  will  be  noted  that  in  many  cases  the 
meeting  of  the  eyebrows  in  the  middle  line  is  associated 
with  the  strumous  diathesis,  and  while  many  of  this  class 
show  remarkable  mental  capacity,  it  seems  to  be  in  com- 
pensation for  distinct  mental  defects  in  the  weaklings  of  the 
family. 

The  evidence  from  several  sources  is  conclusive  that  defects 
in  the  eyeball  itself,  and  in  its  muscular  relations,  are  so  fre- 
quent as  to  necessitate  examination  in  such  mental  cases. 
Without  the  more  searching  examination  of  the  ophthalmic 
surgeon  in  his  consulting-room,  which  would  certainly  add  to 
the  percentage  results,  it  was  found  that  in  100,000  children 
there  were  2,929  suffering  from  defects  of  the  eyes.  These 
do  not  include  errors  of  refraction,  ophthalmoscopic  evidence 
of  defect,  or  nervous  affection  of  movement,  which  last  will 
afterwards  be  referred  to.  It  was  found  that  1,622  suffered 
from   squint,    644  used  convex   glasses — evidence  of  hyper- 


398  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

metropia,  or  long  sight — 142  used  concave  glasses — evidence 
of  myopia,  or  short  sight — 227  suffered  from  disease  of  the 
cornea,  65  from  nystagmus,  and  66  from  ptosis.  In  lesser 
degree  were  noticed  unequal  pupils,  cataract,  etc.  It  is  fair 
to  assume  from  the  simple  fact  that  42  cases  of  myopia  were 
ascertained  on  inquiry,  in  children  not  using  glasses,  and  also 
because  the  inquiry  was  conducted  on  a  large  scale,  and  with- 
out specific  examinations,  that  eye  defects  are  even  more 
common  than  is  here  indicated. 

More  than  twenty  j-ears  ago,  the  late  Professor  Laycock, 
Edinburgh,  directed  attention  to  several  abnormalities  in  the 
development  of  the  ears,  and  these  were  studied  in  relation  to 
various  mental  states.  Since  then,  a  good  deal  of  attention 
has  been  given  to  the  subject,  and  while  data  have  accumu- 
lated, practical  deductions  of  scientific  certainty  can  only  be 
contributory  rather  than  conclusive.  A  well-formed  ear 
must  have  all  the  anatomical  parts  described  in  text-books — ■ 
the  helix,  anti-helix,  tragus,  anti-tragus,  concha,  lobe,  etc. 
Yet  having  these,  there  may  be  defects,  any  of  them  may  be 
abortive  growths  ;  or  the  helix,  instead  of  curving  backwards 
superiorly,  may  be  a  straight  line,  ending  posteriorly  in  an 
angular  prominence.  This  is  regarded  as  evidence  of  atavism 
by  some.  The  lobe  may  be  absent  or  defective,  and  what 
remains  may  be  adherent  to  the  face  ;  but  this  by  itself  has 
not  been  found  to  indicate  much. 

The  size  of  the  ear  and  the  general  shape,  as  also  its  site 
in  relation  to  the  eye,  audits  distance  therefrom,  are  of  more 
significance.  A  large,  coarse,  hairy  ear,  with  pronounced 
convexity  as  seen  from  behind,  is  not  a  good  feature,  espe- 
cially if  there  is  vascular  discoloration  on  its  surface.  The 
position  must  give  anatomical  data  as  to  the  development  of 
the  base  of  the  cranium,  and  the  size  of  the  cranial  vault. 
If  the  point  of  junction  of  the  upper  part  with  the  scalp  is 
on  a  level  with  the  eyebrows,  the  cranial  base  is  evidently 
high  up,  and  the  cranial  capacity,  so  much  less.  As  a  rule,  it 
may  be  taken  as  evidence  of  good  development  if  the  point 
indicated  is  in  the  same  plane  as  the  transverse  axis  of  the 
eyeball. 

Not  much  can  be  said  regarding  the  conformation  of  the 


THE  BACKWARD  AND  FEEBLE-MINDED  399 

nose  as  evidence  pro  or  co7t.  In  some  idiots  we  find  types  of 
nose  that  would  not  disgrace  an  aristocrat — the  remnant,  the 
only  evidence  left,  of  a  good  type  now  extinct.  On  the  con- 
trary also,  we  find  competent  men  and  women  with  very 
insignificant,  ill-shapen  probosces,  and  therefore  we  must 
have  regard  to  the  constitution  underlying  it  all,  and  study 
defects  of  the  nasal  bones  and  cartilages  in  relation  to  diseases 
such  as  scrofula  and  syphilis. 

A  good  deal  may  be  learned  from  an  examination  of  the 
mouth,  not  merely  the  palate,  of  which  so  much  has  been 
written,  but  the  premaxillary  region,  the  submaxillary  region, 
the  development  of  the  teeth,  the  lips,  and  the  apposition  of 
the  lips  and  jaws.  From  time  immemorial,  the  type  given  of 
the  idiot  has  been  described  as  a  slavering,  dribbling  creature, 
with  drooping  lower  jaw  and  gaping  mouth.  The  gaping 
mouth  is  due  to  nervous  defect,  to  muscular  deficiency,  or 
weakness  either  in  the  infra-maxillary  or  labial  muscles, 
probably  in  both  ;  and  it  is  also  a  sign  of  stupidity  far  short 
of  idiocy. 

The  prominence  of  the  premaxillary  region  attracts  atten- 
tion at  once,  especially  because  it  is  so  suggestive  of  rever^ 
sion  to  a  lower  type ;  besides,  it  is  invariably  associated  with 
more  or  less  palatal  deformity,  and  with  prominence  or  pro- 
trusion of  the  incisors.  The  lower  jaw  has  not  attracted 
particular  attention,  and  yet  we  are  in  the  habit  of  judging 
very  much  of  a  man's  character  from  the  size  and  angle  of 
this  part  of  the  face.  A  large  jaw,  short  of  the  prognathous 
type,  and  what  is  called  a  square  jaw — in  other  words,  a 
maxilla  with  a  near  approach  to  the  degree  of  a  right  angle — 
has  been  regarded  as  the  type  of  strength  and  determination 
of  character.  The  opposite  of  this  is  seen  in  the  sloping 
lower  jaw,  with  a  more  or  less  obtuse  angle,  meeting  in  the 
middle  line  in  front,  at  a  more  or  less  acute  angle  with  its 
neighbour  of  the  opposite  side,  and  receding  at  the  chin. 

While  hot  assuming  that  much  stress  should  be  laid  on 
this  kind  of  formation,  I  must  admit  that,  combined  with 
premaxillary  prominence,  I  have  frequently  observed  it  in 
families  having  a  strong  hereditary  neurotic  taint,  and  with- 
out the  conjunctive  stigma  mentioned — at  any  rate,  so  promi- 


400  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

nent  as   has   been   described,   I   have    still   more   frequently 
seen  it,  though  rarely  in  the  same  serious  connection. 

The  development  of  the  teeth,  as  long  ago  pointed  out  by 
Dr.  Langdon  Down,  furnishes  valuable  indications,  and  not 
infrequently  the  abnormalities  of  the  times  and  places  of 
their  appearance  are  seen  in  just  such  cases  of  maxillary 
development  as  have  been  described.  But  not  necessarily 
so,  for  they  may  mark  abnormal  departures  by  themselves 
alone  in  perfectly  well-formed  upper  and  lower  jaws. 

Referring  more  particularly  to  what  is  found  in  idiocy  and 
imbecility,  Langdon  Down  observes  :  '  There  is  a  marked 
postponement  in  the  evolution  of  the  first  teeth.  Looking 
over  my  notes  of  a  ver}^  large  number  of  cases,  I  find  that 
the  first  dentition  is  almost  invariably  postponed.  The  ease 
with  which  dentition  is  effected  varies.  Sometimes  the 
teeth  are  cut  so  easily  that  no  disturbance  of  the  general 
health  is  observed ;  in  others  it  is  the  period  at  which 
violent  convulsive  attacks  are  developed,  imperilling  greatly 
the  feeble  mental  endowment  of  the  child.' 

In  cases  of  feeble-minded  children  (idiots  and  imbeciles) 
he  has  observed  that  '  the  primary  teeth  have  a  more 
temporary  existence  than  usual.  They  are  frequently  dark, 
speedily  become  carious,  and  their  stunted  growth  is  often 
aggravated  by  the  incessant  grinding  of  the  teeth,  which  is 
so  frequent  during  the  infantile  life  of  such  children.  I  have 
been  curious  to  ascertain  the  cause  of  such  grinding.  In 
most  cases  it  appears  to  be  a  kind  of  automatic  movement, 
not  depending  on  the  direct  influence  of  the  will ;  one  of 
those  rhythmic  movements  of  which  there  are  several  among 
children  of  this  class.  In  others  it  would  appear  to  be 
purposely  developed  to  produce  a  monotonous  sound,  which 
imparts  pleasure  to  the  feeble-minded.  Not  only,  however, 
are  the  primary  teeth  ill  developed,  they  are  often  irregularly 
developed  as  to  sequence.  Nothing  but  disorder  is  noticed 
in  their  succession  '  ('  Mental  Affections  of  Childhood  and 
Youth'). 

Speaking  for  a  wider  clientele  of  patients,  and  using  the 
term  '  feeble-minded  '  in  a  larger  sense,  we  may  traverse  the 
foregoing    statement    with    some    interpolations.     Thus,    in 


THE  BACKWARD' AND  FEEBLE-MINDED  401 

many  neurotic  subjects,  early  rather  than  late  development 
of  the  primary  teeth  may  be  observed,  and  in  subjects  not 
evidently  neurotic  the  decay  of  these  teeth  early  is  also 
noticed.  The  chief  point  of  importance  here  is  the  erratic 
and  irregular  appearance  both  as  to  time  and  place  of  the 
secondary  rather  than  of  the  primary  teeth.  This,  again,  is 
very  noticeable  in  syphilitic  and  strumous  cases,  but  the 
character  of  the  teeth  in  the  former  instance  speaks  for  itself. 

The  various  types  of  palate  have  received  a  great  deal  of 
attention,  and  if  as  anatomical  variations  they  were  so 
regarded,  and  little  more,  there  would  not  be  much  requiring 
to  be  unsaid.  Langdon  Down  and  Ireland  have  referred  to 
this  subject,  and  more  recently  Clouston  ('  Neuroses  of 
Development ')  has  examined  criminal  as  well  as  insane 
types,  and  drawn  some  startling  deductions.  It  is  more 
than  probable  that  these  deductions  are  rather  far-fetched, 
and  that  the  data  from  some  non-criminal  people,  if  largely 
drawn  on,  would  have  discounted  these  conclusions  to  a 
considerable  extent.  I  have  frequently  drawn  attention  to 
the  presence  of  broad,  well-formed  palates  in  idiots  and 
imbeciles,  and  placing  alongside  these  cases  insane  patients 
who  were  normal  up  to  a  certain  age,  I  have  in  the  latter 
frequently  seen  narrower  and  more  vaulted  palates.  Still 
further,  I  have  examined  sane  persons  of  undoubted  in- 
telligence and  mental  stability,  and  found  in  not  a  few  of 
them  palates  which,  according  to  these  foregoing  deductions, 
had  been  fixed  on  the  wrong  class  of  people. 

The  argument,  moreover,  that  these  vaulted  or  saddle- 
shaped  palates  indicate  a  contracted  cranial  base  is  founded 
on  the  assumption  that  there  is  no  bony  compensation  else- 
where, of  which  we  have  no  proof.  The  roof  of  the  palate 
is  not  by  any  means  equivalent  to  the  base  of  the  brain  ;  in 
fact,  a  narrow  palate  may  be  associated  with  a  broad  base, 
as  the  wings  of  the  sphenoid,  etc.,  may  be  more  than  usually 
expanded.  Dr.  T.  Cla3^e  Shaw  has  endeavoured  to  prove 
that  a  highly-arched  palate  is  not  a  sign  of  the  existence  of 
idiocy  or  imbecility,  and  that  a  study  of  the  palate  can  afford 
no  clue  to  the  mental  faculties.  And,  assuming  it  to  be  true 
that   a  contracted   cranial   base    accompanies   a  vaulted  or 

26 


402  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

saddle-shaped  palate,  its  value  is  minimized  by  the  fact  already 
stated,  that  within  certain  limits  the  brain  is  adaptable  both 
in  its  external  displacement  and  in  the  relative  arrangements 
of  its  gray  and  white  matter.  The  data  as  to  the  deformities 
of  palate  found  in  the  London  schools  are  insufficient,  because 
they  are  not  classified  in  quite  the  same  way  as  Clouston's. 
The  palatal  defects  noticed  amounted  to  2,127  in  100,000. 
This  is  an  exceedingly  small  proportion,  and  would  seem  to 
justify  Clouston's  assumption,  if  the  same  defects  were  con- 
noted in  both  investigations.  It  must,  however,  be  observed 
that  the  London  Committee  dealt  with  children  still  plastic 
and  undeveloped,  while  Clouston's  results  were  obtained  by 
an  examination  of  adults. 

That  the  formation  of  the  palate  is  a  matter  of  some 
importance  must  not  be  denied,  but  to  prognosticate  that  a 
man's  future  mental  history  must  be  clouded  sooner  or  later, 
and  that  a  boy  will  run  great  risk  of  mental  breakdown 
during  puberty  or  adolescence  because  he  has  a  highly 
arched  and  narrow — so-called  '  nervous  ' — palate,  or,  worse 
still,  saddle-shaped  palate,  with  the  pommel  well  marked,  is 
no  more  logical  than  to  say  that  a  man  has  heart  disease 
because  he  suffers  from  palpitation.  It  is  a  contributory 
sign  of  perhaps  some  significance,  as  indicating  a  possible 
nervous  taint,  but  no  more  can  be  said  for  it. 

The  forms  of  palate  looked  for  by  the  London  Committee 
were  these  :  (i)  Palate  narrow — without  being  otherwise 
altered  antero-posteriorly,  or  in  the  roof,  the  palate  may  be 
contracted  laterally  in  the  space  between  the  alveolar  pro- 
cesses. (2)  V-shaped  palate — pointed  more  or  less  sharply  at 
its  anterior  extremity  (premaxilla),  the  alveolar  processes 
being  nearly  straight  lines,  meeting  at  their  anterior  extremi- 
ties at  an  acute  angle.  (3)  Palate  arched  or  vaulted,  thus  devi- 
ating from  the  normal  in  the  vertical  plane  with  a  high 
roof.  (4)  Palate  cleft,  a  deformity  which  may  affect  the 
hard  or  the  soft  palate.  (5)  Flat,  and  horseshoe  types.  No 
observations  were  offered  by  the  committee  as  to  the  relative 
value  of  these  types. 

On  the  subject  of  the  open  mouth,  they  remark  that  'the 
open  mouth  in  a  child  usually  depends  upon  the  dropping  of 


THE  BACKWARD  AND  FEEBLE-MINDED  403 

the  lower  jaw.  This  habitual  dropping  of  the  jaw  depends 
upon  want  of  tone  in  the  temporal  and  masseter  muscles, 
rather  than  on  spasm  of  the  depressors.  It  may  be  called 
to  mind  that  this  want  of  tone  is  due  to  lessened  stimulus  of 
the  motor  division  of  the  fifth  nerve,  whose  sensory  branches 
are  largely  distributed  to  the  meninges.  Weakness  of  this 
nerve  leads  to  open  mouth,  irritation  of  it  to  tooth-grinding. 
Of  course,  this  condition  of  '  mouth  open  '  is  only  to  be 
looked  upon  as  a  nerve  sign  when  the  respiratory  passages 
are  unobstructed. 

Developmental  defects  are  liable  to  occur  in  any  part  of 
the  body  structure  and  conformation,  and  in  any  of  the 
organs  or  functional  systems.  That  many  of  them — the 
supernumerary  or  cervical  rib,  for  example — should  be  re- 
garded merely  as  anatomical  curios  rather  than  pathogno- 
monic signs  goes  without  saying.  Not  only  so,  but  many 
that  have  any  pathognomonic  meaning  at  all  have  it  in  pro- 
portion to  the  preponderance  of  other  abnormalities  of 
structure  and  function. 

Of  organic  defects,  the  most  frequent  is  in  the  circulatory 
system,  in  the  heart  and  aorta  especially,  but  by  no  means 
confined  to  these  parts,  for  in  the  vascular  arrangement  and 
distribution  many  striking  deviations  are  noticeable.  It  is 
exceedingly  probable  that  in  the  brain,  if  we  could  have 
an  opportunity  of  studying  such  cases  post-mortem,  more 
or  less  marked  departures  from  the  true  anatomical  size  and 
relations  would  be  observed.  This  at  least  is  certain,  that 
in  the  imbecile  and  the  idiot  many  remarkable  eccentricities 
of  size,  asymmetrical  arrangement  and  distribution  may  be 
observed ;  and  when  these  are  seen  at  the  base,  and  particu- 
larly in  the  Circle  of  Willis  and  its  offshoots,  it  is  easy  to 
understand  the  lopsidedness  of  brain  and  the  abnormal 
deviations  of  nervous  and  mental  constitution  which  must 
ensue.  The  effects  of  a  congenitally  small  heart  and  aorta 
are  seen  in  the  volume  and  force  of  the  circulation,  and, 
although  cold  and  bluish  hands,  feet,  and  other  terminal 
parts  are  accounted  for  by  defective  vis  nervosa,  and  by 
muscular  inertia,  in  not  a  few  cases  the  heart  and  aorta 
have  their  share  in  the  production  of  these  conditions. 

20 — 2 


404  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

The  condition  of  the  respiratory  system  is  not  organically 
defective  as  a  rule,  but  the  vis  nervosa  here  as  elsewhere  is 
sometimes  at  a  low  ebb,  and  shallow  respiration  is  the 
result.  It  may  be  taken  as  a  rule,  which  applies  to  all  the 
other  organic  parts  and  connections,  that  where  there  is 
a  general  deficiency  of  nervous  force,  the  result  must  be 
sluggish  activity,  slowness  of  functional  processes,  and  a 
minimum  vital  result.  It  is  a  well-known  fact  that  in  the 
idiot  and  imbecile  reflex  action  is  much  impaired,  and,  even 
more  than  in  the  lunatic,  there  may  be  a  phthisical  process 
without  outward  sign,  night  sweats,  cough,  spit,  etc.,  being 
absent.  This  serves  to  illustrate  how  intimately  the  nervous 
system — the  reflexes  in  particular — is  implicated  in  these 
states,  and  how  important  it  is  from  a  practical  point  of 
view  to  keep  these  facts  in  remembrance. 

Many  other  developmental  defects  might  be  added  ;  but, 
as  already  observed,  they  may  be  mere  anatomical  curios, 
and  all  that  is  necessary  is  to  direct  attention  to  abnormalities 
of  the  spinal  column — various  kinds  and  degrees  of  curvature, 
spina  bifida,  etc. ;  to  asymmetrical  development  of  the  limbs, 
perhaps  as  a  result  of  congenital  or  infantile  paralysis,  bone 
and  joint  disease;  and  to  asymmetrical  parts  of  the  body,, 
such  as  difference  in  size  of  the  mammae,  asymmetry  of  the 
pelvis,  etc. 

The  Evidence  of  Nervous  Dynamics — Abnormal 
Nerve  Signs. 

So  far,  in  dealing  with  anatomical  data,  we  have  had  to 
do  with  statics — with  structure  rather  than  movement,  and 
with  evidence  the  clinical  value  of  which  must  be  difficult  to 
properly  estimate.  The  evidence  of  movements — clinical 
dynamics — brings  us  nearer  to  the  seat  of  nervous  and 
mental  activity,  and  it  is  here  where  considerable  results 
may  be  looked  for,  even  when  the  developmental  stigmata 
are  by  no  means  striking  or  apparent.  The  study  of  what 
he  calls  nerve  signs  is  one  which  Warner  has  made  peculiarly 
his  own.  In  observing  spontaneous  and  voluntary  move- 
ments in  childhood  and  youth,  various  postures  and  balances 
of  the  body  and  its  parts,  he  has  been  able  to  group  a  large 


THE  BACKWARD  AND  FEEBLE-MINDED  405 

number  of  nerve  signs,  some  of  which  give  clinical  data  of 
no  small  importance. 

As  we  should  expect,  the  face  is  regarded  as  the  most 
accurate  index  of  the  action  of  the  brain,  and  this  region  he 
conveniently  divides  into  three  zones  :  (i)  the  upper,  the  frontal 
above  the  line  of  the  eyebrows  ;  (2)  the  middle,  extending 
downwards  from  the  line  of  the  eyebrows  for  a  very  short 
distance  to  the  lower  margin  of  the  orbits,  what  may  be  called 
the  eye  zone  ;  (3)  the  lower  is  the  most  extensive,  and  includes 
the  rest  of  the  face.  Warner  thinks  the  greatest  degree  of 
expression  is  seen  in  the  frontal  region,  mainly  produced  by 
the  action  of  the  frontal  and  corrugator  muscles.  Regarding 
the  abnormal  nerve  signs  that  may  be  observed  and  require 
to  be  looked  for,  the  following  are  notes  from  the  London 
Committee's  report : 

'  Expression  Defective. — We  may  describe  the  visible  mus- 
cular action  seen  in  a  face,  and  still  there  may  be  an  expres- 
sion in  it  which  entirely  baffles  description  in  anatomical 
terms.  Further,  a  face  may  be  balanced  or  moved  abnormally 
by  the  action  of  certain  muscles,  and  yet  it  may  carry  upon 
it  a  good  expression.  We  may  describe  action  in  the  frontal 
muscles,  the  corrugators,  the  orbicularis  oculi,  etc.,  and  over 
and  above  this  we  have  the  general  expression  of  the  face 
superadded.  Certain  terms  are  useful  in  describing  expres- 
sion ;  there  may  be  a  fixed  expression,  want  of  variation, 
i.e.,  one  fixed  uniform  action  or  balance  of  muscular  tone,  or 
we  may  have  to  use  more  general  terms,  such  as  "  defective  " 
or  "  bad."  There  may  be  no  expression,  i.e.,  none  other 
than  that  indicated  by  form  or  modelling  of  the  features.' 

'  Frontals  Over-acting. — The  frontal  muscles  almost  always 
act  symmetrically,  at  the  same  time  and  in  similar  degree ; 
their  action  produces  horizontal  creases  in  the  forehead, 
which  may  be  deep  if  these  act  strongly.  Sometimes  the 
muscles  are  seen  working  under  the  skin  in  vermicular 
fashion,  with  an  athetoid  movement  ;  in  other  cases  the 
action  is  fine,  producing  minute  creases,  and  what  might  be 
called  a  dull  forehead.  This  over-muscular  action  does  not 
necessarily  erase  expression.  Such  over-action  may  be  seen 
in    children    from  earliest    infancy  upwards ;    the  condition 


4o6  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

may  be  temporary,  and  having  lasted  a  sufficient  number  of 
years  to  produce  creases  in  the  forehead,  it  ma}'  pass  away. 
These  muscles  are  often  more  quiet  when  the  child  is  at 
work,  or  being  talked  to,  than  when  let  out  to  play ;  the 
mental  attitude  termed  qtiiet  attention  is  that  under  which 
the  frontal  area  is  the  most  quiet.' 

'  Cornigation. — Corrugation,  or  knitting  of  the  eyebrows,  is 
due  to  over-action  or  hypertonicit}-'  of  the  corrugator  muscles  ; 
vertical  creases  are  produced  by  over-action,  and  a  fine 
wrinkling  of  the  skin,  producing  local  dulness,  is  sometimes 
seen.  This  sign  seems  more  closely  associated  than  any 
other  single  sign  with  some  forms  of  mental  stress,  and  may 
be  seen  in  children  suffering  from  the  effects  of  fright,  illu- 
sions, etc. ;  it  may  form  part  of  a  fixed,  immobile  expression. 
Corrugation  may  be  associated  with  overaction  of  the  frontals 
in  a  similar  athetoid  defect,  producing  square  creases  vertical 
and  horizontal,  or,  in  finer  degree,  the  combined  action  may 
produce  a  dull  forehead.  When  the  athetoid  condition  is 
present,  we  cannot  judge  of  the  mental  state  by  such  ex- 
pression.' 

'  Orbicularis  Oculi  relaxed. — In  a  strong,  well-toned  face  the 
lower  eyelid  appears  clean-cut  and  well  moulded,  and  the 
rotundity  of  the  eyeball  and  convexit}^  of  the  lower  lid  are 
seen ;  this  sharpness  is  due  to  the  good  tone  of  the  orbicu- 
laris oculi.  When  this  muscle  is  relaxed  and  toneless,  the 
skin  under  the  lower  eyelid  bulges  forward,  and  is  baggy. 
This  relaxed  condition  is  indicative  of  fatigue  and  exhaustion, 
and  is  seen  in  the  nerve  depression  accompanying  severe  and 
incessant  headaches;  these  puffy  eyes  are  usually  symmetrical. 
That  the  condition  is  muscular  is  demonstrated  by  making 
the  patient  laugh,  when  the  swollen  condition  is  removed.' 

'  Eye  Movements  defective. — Some  children,  when  an  object 
is  held  in  front  of  them  and  then  moved,  follow  it,  not  with 
the  movement  of  the  eyes,  but  with  the  head,  keeping  the 
eyes  fixed.  In  other  cases  there  are  restless,  uncontrolled 
movements  of  the  eyes.  Both  conditions  are  included  under 
this  heading ;  the  former  is  most  commonly  met  with ;  the 
two  conditions  may  co-exist.' 

'  Grinning  and  Over-smiling. — Grinning  or  over-smiling  is 


THE  BACKWARD  AND  FEEBLE-MINDED  407 

usually  symmetrical,  but  may  be  unequal  on  the  two  sides  of 
the  face.  With  low-class  brain  conditions,  it  is  sometimes 
seen  as  almost  the  only  facial  movement,  occurring  upon 
any  stimulus  as  a  uniform  movement,  almost  as  athetoid  in 
character  as  the  frequent  over-action  of  the  frontal  muscles.' 

'  Habitual  grinning,  and  in  particular  the  finer  movements 
of  over-smiling,  often  leave  permanent  naso-labial  creases 
marked  upon  the  skin.  These  may  remain  after  the  habit 
has  been  lost.  If  the  skin  be  thin,  a  duphcate  or  triplicate 
naso-labial  crease  may  be  formed.  This  is  more  common 
in  neurotic  than  in  imbecile  subjects.' 

Further  evidences  may  be  looked  for  in  the  attitude 
of  children  standing  and  sitting,  the  gait,  the  balance  of 
the  body  and  its  several  parts,  and  locomotion.  In  the 
attitude  we  can  detect  want  of  muscular  tonicity,  stooping, 
drooping  of  the  head,  limpness  and  general  flaccidity,  or  the 
reverse.  If  a  child  is  made  to  extend  the  arms  straight  out 
from  the  shoulders,  we  may  detect  weaknesses  in  the  balance 
of  the  body  as  a  whole,  in  the  unsustained  elevation  of  the 
arms,  in  the  balance  of  the  hands.  The  hands  give  a  very 
fair  index  of  nervous  and  mental  character — their  size  and 
grip,  the  degree  of  extension  of  the  fingers,  and  the  position 
of  the  thumb.  A  weak  hand  is  not  difficult  to  recognise, 
and  the  nervous  hand  speaks  for  itself.  The  manner  of 
walking  should  be  observed,  and  the  power  of  endurance  in 
this  respect.     These  also  give  indications. 

The  State  of  Nutrition. — '  Persistent  defects  of  nutrition,  in 
spite  of  good  feeding,  are  symptomatic  of  defect  of  original 
constitution,  and  are  not  infrequently  associated  with  mental 
deficiency  '  (Shuttleworth).  This  fact  was  clearly  recognised 
by  the  London  Committee,  and  the  report  bears  out  that 
defects  of  nutrition  were  more  frequently  seen  in  girls  than 
in  boys.  The  girls  were  more  frequently  dull,  and  the  boys 
in  larger  number  per  cent,  exhibited  nerve  signs.  The  state 
of  nutrition,  it  is  scarcely  necessary  to  say,  must  have  an 
important  bearing  on  the  quality  of  the  nervous  system,  and 
on  the  activity  and  stability  of  the  brain.  In  this  con- 
nection regard  must  be  had  to  all  conditions  of  ill-health  in 
childhood,  and  the  history  of  the  child's  ailments  and  their 


4o8  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

nervous  and  mental  effects,  as  well  as  their  interruption  of 
the  progress  of  education,  should  not  be  overlooked.  In 
judging  of  the  nutritive  activity  of  any  child,  regard  must  be 
had  to  the  following  points :  (i)  The  type  of  constitution, 
for  there  are  naturally  small,  thin,  firm,  and  hardy  children, 
and,  on  the  other  hand,  children  of  full  size,  but  soft  and 
flabby ;  (2)  a  pinched  face  is  no  proof  of  malnutrition,  nor  is 
a  large  fat  face  evidence  that  the  body  and  limbs  are  well 
nourished — the  child  should  be  examined  all  over ;  (3)  re- 
movable causes,  hygienic  and  constitutional ;  (4)  the  diet  of 
the  patient. 

The  Senses. — While  the  condition  of  the  special  senses  is 
of  first  importance,  it  is  well  here  to  say  a  word  in  passing 
as  to  the  state  of  sensation  generally.  Some  children  are 
extremely  sensitive,  and  any  peripheral  disturbance  reacts  on 
the  motor  system  with  more  or  less  intensity.  It  may  be 
only  to  induce  restlessness  or  twitches  ;  but  convulsions  are 
quite  possible  in  extreme  cases.  A  history  of  such  may, 
of  course,  have  a  grave  meaning  in  considering  the  mental 
prognosis.  Other  children  are  lethargic,  in  the  sense  that 
they  are  not  easily  disturbed  by  sensory  stimuli,  and  this 
may  be  so  marked  as  to  approach  to  anaesthesia.  Both 
examples  are  extrem.es,  and  require  to  be  kept  in  view. 

The  study  of  the  special  senses  is  of  necessity  a  fruitful 
means  of  observation.  The  gateways  of  knowledge,  as  they 
have  been  called,  must  be  intact  and  functionally  acute  in 
order  to  increase  education  and  mature  mental  develop- 
ment. In  the  study  of  the  degree  of  mental  development 
and  activity  of  a  child,  the  examination  therefore  would  be 
manifestly  incomplete  if  the  conditions  of  the  special  senses 
were  left  out  of  account.  By  testing  them  we  are  able  to 
estimate  their  range  of  receptiveness,  and  the  reaction-time 
of  mental  processes. 

A  backward  boy,  who  is  the  despair  of  his  parents,  who 
can  apply  himself  for  only  short  periods  at  a  time  to  his 
lessons,  and  makes  little  progress  on  account  of  easily  induced 
fatigue,  may  be  suffering  from  inherent  weakness  of  brain, 
or  the  headaches  of  which  he  complains  may  be  due  to  eye- 
strain, and  the  mental  fatigue  may  be  a  result  of  them.     In 


THE  BACKWARD  AND  FEEBLE-MINDED  409 

all  doubtful  cases,  therefore,  it  is  well  to  examine  the  eyes, 
and  in  cases  of  squint,  astigmatism,  myopia,  and  hyper- 
metropia  a  competent  oculist  should  be  consulted. 

Deafness  is  a  condition  which  we  notice  from  time  to 
time  as  an  episode  in  the  development  of  mental  cases,  an 
episode  sometimes  of  grave  significance.  Deaf  boys  always 
look  stupid,  and  are  frequently  backward  or  feeble-minded. 
The  degree  of  deafness  and  the  cause  of  it  have  to  be  taken 
into  account,  and  also  its  relation  to  the  function  of  speech. 
Apart  altogether  from  the  case  of  deaf-mutes,  deafness  short 
of  absolute  inability  to  hear  must  have  a  delaying  influence 
in  speech  development.  If  all  apparently  stupid  boys  had 
their  hearing  tested,  and  where  impaired  successfully  attended 
to,  there  is  no  question  that  education  would  be  more  rapid, 
and  the  dull  boy  would  brighten  up  in  intellect  and  expres- 
sion, and  improve  in  speech. 

What  has  just  been  said  on  this  subject  might  be  ampli- 
fied ;  but  there  is  no  occasion  for  further  remark  than  this, 
that  every  doubtful  case  should  be  examined  most  par- 
ticularly regarding  the  acuteness  and  the  all-round  receptive- 
ness  of  the  special  senses.  Defects  of  touch,  smell,  and 
taste  are  less  noticed  ;  but  pro  tanto  they  are  contributory 
causes  of  mental  deficiency.  Of  these  three  touch  is  most 
important,  then  smell  and  taste ;  and  it  is  astonishing  how 
much  can  be  learned  by  the  exercise  of  the  sense  of  touch  alone. 

The  Examination  of  the  Mental  Condition. — This  it  is  which 
gives  the  actual  diagnosis  of  the  degree  of  mental  dulness, 
slowness,  or  backwardness.  The  physical  stigmata  to  which 
I  have  directed  so  much  attention,  the  nervous  signs,  the 
state  of  nutrition,  and  the  acuteness  of  the  special  senses, 
may  directly  or  indirectly  assist  in  explaining  the  reasons  of 
this  mental  deficiency ;  but  the  diagnosis  of  the  amount  of 
the  defect  is  of  importance  with  a  view  to  treatment,  and, 
having  applied  treatment,  in  enabling  us  to  judge  from  time 
to  time  to  what  extent,  if  any,  the  defect  is  being  removed. 

It  must  again  be  repeated  that  the  pace  of  education  and 
mental  development  is  not  the  same  for  all  boys  and  girls, 
and  while  it  may  be  useful  to  compare  a  given  case  with 
different  boys  of  varying  ages,  so  as  to  measure  the  rate  of 


4IO  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

mental  development,  no  arbitrary  conclusion  should  be 
drawn  from  this  alone.  Take  for  example  two  bo3's  in  the 
same  class  at  school — and  the  following  is  taken  from  life. 
One  is  six  years  old,  the  other  seven  and  a  half  years  of  age. 
The  younger  boy,  B.,  is  smaller  for  his  age,  but  well  knit,  hard 
and  wiry,  and  first  favourite  in  the  plavground.  A.  is  larger 
for  his  age,  ruddy,  softer,  given  to  mooning  about  rather  than  , 
play.  B.  is  dux  ;  A.  is  dunce.  The  schoolmaster  promises 
B.  a  shilling  if  he  keeps  at  the  top  of  his  class  all  day.  He 
wins  the  prize,  but  the  master  has  a  short  memory,  and  B. 
is  too  shy  to  remind  him.  A.  offers  to  do  so  provided  he 
gets  half  the  money.  B.  agrees.  The  prize  is  awarded  and 
divided. 

These  two  boys  started  life  under  precisely  the  same  con- 
ditions of  parentage,  home  life,  and  school  life — the  environ- 
ment was  in  no  way  different.  B.  forged  steadily  ahead  ; 
A.  lagged.  B.  had  morally  a  different  character ;  he  had 
physical  courage,  and  would  never  try  to  justify  himself  if 
found  in  fault,  but  would  take  his  chastisement  manfully. 
A.,  of  feebler  physical  and  moral  courage,  and  of  more 
sensitive  organization,  would  evade  responsibility,  and 
morally  was  somewhat  defective.  He  was  more  calculating 
and  observant  and  far-seeing,  but  was  pronounced  a  dull, 
stupid  boy,  and  actually  grew  up  with  the  idea  firmly  rooted 
in  his  mind  that  his  intellect  was  below  par.  The  school- 
master had  no  good  opinion  of  him,  and  thrashed  him  so 
frequently  that  the  boy  got  more  and  more  nervous,  and  was 
afflicted  with  a  stutter  for  several  years.  Even  then  he  was 
observant  enough  to  recognise  the  letters  he  stumbled  over, 
and  so  to  frame  sentences  as  to  avoid  stuttering  at  the  begin- 
ning of  a  sentence. 

A.  passed  through  puberty  like  other  boys ;  there  were  no 
nervous  signs;  he  had  still  grown  ahead  of  B.,  but  B.  now 
began  to  stretch,  and  A.  made  little  further  progress.  B., 
by  the  way,  was  rather  given  to  talking  in  his  sleep,  and  would 
even  go  about  the  house  in  a  state  of  somnambulism.  This 
A.  never  did.  The  older  bo}-  after  puberty  began  to  wake  up  ; 
he  was  really  more  imaginative  than  his  brother  ;  he  began  to 
study  with  an  object,  and  eventually  came  up  alongside  his 


THE  BACKWARD  AND  FEEBLE-MINDED  411 


younger  brother,  whose  pace  slowed  considerably.    The  moral 
and  emotional  defects  of  childhood  entirely  disappeared. 

I  have  gone  thus  fully  into  the  case  of  these  two  boys  in 
order  to  illustrate  the  fact  that  no  two  boys  evolve  on 
precisely  the  same  lines,  or  equally  in  all  directions,  nor  at 
the  same  pace.  Nor  must  one  despair  if  one  boy  is  morally 
deficient  for  the  first  years  of  his  life,  nor  be  too  sanguine 
because  another  boy  is  truthful ;  it  may  be  that  his  truthful- 
ness is  merely  because  he  cannot  think  a  lie.  Again,  it 
should  be  remembered  that  up  to  puberty  some  boys  are 
very  slow  at  school ;  but  there  is  nothing  in  their  physical 
conformation  to  disquiet  their  parents,  and  their  general 
observation  is  all  that  can  be  desired.  During  the  period  of 
puberty  boys  and  girls  often  come  to  a  standstill  educa- 
tionally, and  it  is  well  not  to  expect  much  from  them  for  a 
considerable  period  about  this  time ;  they  are  all  the  more 
likely  to  make  good  progress  after. 

A  further  point  of  importance  is  to  judge  the  boy  not 
merely  by  the  results  of  school  education,  for  education  takes 
a  far  wider  range  than  mere  school  instruction.  Many  boys 
who  are  beheved  to  be  trifling  all  the  time  may  be  observing 
and  acquiring  to  as  good  purpose  as  the  more  attentive  and 
diligent  scholars.  So  long  as  a  boy  is  getting  object  lessons, 
especially  in  the  first  years  of  school  life,  his  senses  are  being 
quickened,  his  faculty  of  observation  is  being  cultivated,  and 
he  is  multiplying  his  knowledge  of  concrete  facts  and  abstract 
ideas,  to  be  the  foundation  on  which  will  afterwards  rest 
much  of  his  book  knowledge.  The  loss  of  a  few  years  at 
school  at  the  beginning  of  a  boy's  career  is  not  of  so  m.uch 
account,  and  it  is  surprising  what  strides  he  can  make  later  on. 

In  any  inquiry  as  to  the  mental  condition  of  a  backward 
boy,  or  a  boy  suspected  to  be  feeble-minded,  a  system 
should  be  followed  so  that  nothing  of  importance  would  be 
left  out.  The  first  point  of  clinical  importance  is  to  test  the 
time-reaction  through  the  various  senses.  If  the  senses  have 
not  already  been  examined,  this  gives  a  fair  general  idea  of 
their  integrity.  To  quicken  the  sense  of  pain  by  pinching 
the  skin  will  also  reveal  the  temper  of  the  boy,  and  otherwise 
also  his  emotional  character,  for  he  may  laugh  or  cry.     The 


412  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

reaction-time  will  show  his  mental  pace  so  far  as  simple 
observation  is  concerned. 

When  the  test  is  applied  to  more  complicated  mental  pro- 
cesses, the  reaction-time  may  be  quicker  under  some  tests  than 
under  others ;  and  here  becomes  evident  some  special  aptitude, 
as,  e.g.,  for  arithmetic,  mathematics,  poetry,  languages.  One 
boy's  psychic  element  in  reaction-time  is  quick  for  arithmetic, 
slow  for  grammar,  and  quick,  again,  for  seeing  the  solution  of 
problems  in  Euclid,  while  with  another  the  case  is  just  the 
other  way.  If  the  reaction-time  is  slow  in  any  direction,  it 
must  not  be  inferred  that  it  will  always  be  so,  for  many  boys 
ultimately  excel  in  those  very  subjects  which  are  at  one  time 
the  most  difficult  for  them  to  comprehend.  The  reaction- 
time  is  also  judged  of  by  the  responsiveness  in  school-drill. 
Here  also  may  be  obtained  indications  as  to  decision  of 
character — the  boys  who  lead,  and  those  who  follow. 

The  faculty  of  attention  may  be  difficult  to  arrest  for  any 
length  of  time,  and  without  this  faculty,  and  that  of  observa- 
tion duly  applied,  education  does  not  make  much  progress. 
But  it  has  to  be  noted  whether  at  all  times  this  facult}'  is 
more  or  less  in  abeyance.  Is  the  same  boy  as  restless, 
inattentive,  and  purposeless  at  play  as  at  school  ?  What 
does  he  do  with  his  recreation-time  ?  These  inquiries  must 
be  made;  and  unless  he  is  listless  and  unimaginative,  there 
may  still  be  good  hope  for  him.  As  already  remarked, 
attention  to  the  state  of  the  sight  will  assist  negatively  or 
positively  in  determining  the  cause  of  marked  inattention. 

The  memory  should  be  tested.  Some  boys  have  marvellous 
gifts  in  this  way,  while  others  feel  it  so  hard  to  remember 
that  school-hours  are  very  trying,  and  they  would  rather 
get  away  from  lessons  altogether.  School  children  find 
instinctively  that  repeating  their  lessons  aloud  makes  them 
more  easily  remembered.  This  is,  again,  on  the  principle  of 
the  summation  of  stimuli ;  for  with  some  the  eye  impresses 
memory  more  (visual  memory),  while  with  others  the  ear  does 
so  (auditory  memory).  Some,  again,  require  not  only  these 
senses  to  aid  memory,  but  object  lessons  and  associations  of 
ideas  as  well.  It  may  be  found  with  backward  boys  that  the 
difficulty  is  here,  the  memory  being   unimpressionable  and 


THE  BACKWARD  AND  FEEBLE-MINDED  413 

unretentive.  Every  idea  requires  to  be  nailed  down  by 
some  object  lesson,  and  an  association  of  ideas,  artificial  it 
may  be,  has  to  be  inculcated  in  order  to  build  up  a  memory 
of  things.  It  is  a  most  laborious  process ;  but  education 
acquired  in  this  way  is  most  persistent,  and  such  people  are 
said  to  have  good  memories.  This  shows  how  mistaken 
notions  arise  ;  but  it  ought  to  be  borne  in  mind  that  memory 
is  not  equally  impressionable  on  all  subjects,  and  some 
apparently  dull  boys  remember  some  things  very  well. 

The  speech  function  may  be  affected,  and  slowness  of 
speech  or  stuttering  may  be  observed.  In  the  latter  case 
the  fault  is  in  the  motor  mechanism  of  speech  ;  but  in  the 
former  it  is  more  likely  to  be  in  the  mental  processes,  slow- 
ness and  hesitation  of  thought,  or  it  may  be  a  faulty  memory 
of  words,  delaying  the  utterance  of  speech.  It  often  becomes 
worse  where  the  true  nature  of  the  defect  is  not  recognised, 
and  not  properly  attended  to ;  and  teachers  who  lose  their 
tempers  with  such  boys,  and  those  who  poke  fun  at  them, 
deserve  to  be  censured.  Such  treatment  is  not  only  unkind,, 
but  serves  to  perpetuate  a  condition  that  may  otherwise  be 
temporary  and  curable.  Such  boys  are  often  nervous,  sus- 
ceptible, and  timid,  and  this  ought  to  be  recognised. 

Further  examination  is  not  necessary  beyond  an  inquiry 
into  the  boy's  general  character  and  conduct,  his  usual 
temper,  emotional  disposition,  moral  attributes,  and  his 
sleep.  These,  of  course,  are  well  worthy  of  attention  ;  but 
it  is  not  necessary  to  enlarge  further  on  the  subject.  It  may 
be  useful,  however,  to  bring  together  the  threads  of  this 
chapter  in  the  form  of  the  following  scheme  of  clinical 
examination  for  all  mental  cases  below  par. 

{a)  Defects  in  Development. — (i)  Height  and  weight  should 
be  noted,  and  compared  with  standard  of  a  given  age. 
(2)  Cranial  abnormalities  in  size  and  form,  bosses  and 
ridges.  (3)  The  principal  features — the  eye,  ear,  nose,  and 
mouth,  position,  relation  of  parts,  absence  or  deformity  of 
the  whole  or  parts,  the  palate,  the  premaxillary  region,  the 
submaxillary  region,  the  development  of  the  teeth,  the  form 
and  size  of  the  lips,  and  the  apposition  of  lips  and  jaws. 
(4)  Developmental  defects  in  the  body  or  its  parts,  the  heart 
aad  circulation,  asymmetry,  etc. 


414  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

{b)  The  Evidence  of  Nervous  Dynamics — Abnormal  Nerve 
Signs. — (i)  Facial  expression  observed  in  three  zones — above 
the  eyes,  on  the  level  of  the  eyes,  below  the  eyes  ;  the  general 
expression  ;  frontals  over-acting ;  orbicularis  oculi  relaxed  ; 
eye  movements  defective  ;  grinning  and  over-smiling;  posture, 
balances,  the  hands,  spine,  the  gait,  locomotion. 

(c)  The  State  of  Nutrition. — A  general  examination  required, 
as  also  an  inquiry  as  to  the  previous  health  and  illnesses  of 
the  child. 

(d)  The  Senses. — And  to  begin  with  the  condition  of  ordinary 
sensation  ;  two  extremes — the  hyperaesthetic  and  the  anaes- 
thetic. A  careful  examination  of  all  the  special  senses  is 
important. 

(e)  The  Mental  Condition. — Compare  with  other  boys  of 
different  ages,  not  only  as  regards  school  education,  but 
general  knowledge.  No  arbitrary  conclusion  to  be  drawn 
from  this  alone.  Test  reaction-time  through  the  various 
senses ;  the  faculty  of  attention  and  observation  ;  memory 
to  be  tested  by  visual  and  auditory  impressions ;  object  lessons 
and  the  association  of  ideas ;  speech  as  a  motor  function, 
and  as  a  result  of  mental  processes  ;  character  and  conduct ; 
usual  temper;  emotional  disposition;  moral  attributes;  sleep. 

Treatment. 

The  treatment  of  the  mentally  -  feeble  and  backward 
children  must  evidently  call  for  much  care  and  discrimina- 
tion, a  more  intimate  circumspection  of  child  life  and  habits, 
and  more  tact.  From  what  has  been  already  said,  several 
indications  for  treatment  must  be  obtained. 

Although  little  has  been  said  of  moral  deficiencies  or 
slowness  of  moral  development,  it  is  necessary  to  emphasize 
the  necessity  for  careful  inquiry  and  judicious  treatment. 
The  case  is  well  put  by  Shuttleworth  as  follows :  '  If  good 
moral  training  be  a  prime  essential  in  every  system  of  educa- 
tion, it  is  specially  so  in  the  case  of  mentally  deficient 
children.  Not  that  the  mentally-feeble  child  is  by  nature 
morally  worse  than  the  ordinary  child,  but  his  weakness 
makes  him  more  pliable,  and  an  evil  example — not  to  say 
precept — may  in  his  case  be  specially  injurious.   ...    As 


THE  BACKWARD  AND  FEEBLE-MINDED  415 


regards  moral  discipline,  coaxing,  not  coercion,  must  be  the 
guiding  principle  .  .  .  the  "cowed"  child  will  be  a  cowardly 
child,  with  no  pluck  or  spirit  to  advance  itself.  As  Roger 
Ascham  remarks  with  regard  to  the  ordinary  pupil,  "He 
must  in  no  wise  be  beaten  into  the  hatred  of  learning,"  and 
not  only  in  the  scholastic,  but  in  the  general  management  of 
the  mentally-deficient  child,  love  must  be  the  all-pervading 
principle.  At  the  same  time,  judicious  firmness  must  be 
exercised,  and  consistency  in  word  and  deed,  combined 
with  tact,  are  essential  to  moral  influence.'  If  these  instruc- 
tions are  sincerely  carried  out,  the  motto  Nil  desperandum 
may  be  hopefully  entertained  in  not  a  few  cases,  even  if  pro- 
gress is  slow. 

The  various  physical  and  nervous  defects,  the  bodily 
health  and  malnutrition,  must  receive  attention  so  far  as 
they  are  amenable  to  treatment.  Physical  education  should 
be  pursued  with  discretion,  and  '  systems  '  of  gymnastics 
should  not  be  too  rigidly  enforced,  but  altered  and  adapted 
to  each  particular  case.  Here  more  than  anywhere  else  does 
the  old  saying  hold  good.  Mens  sana  in  corpore  sano.  Rest  and 
sleep  should  receive  their  due  meed  of  consideration.  Rest 
in  the  recumbent  position,  apart  from  sleep  altogether,  is 
favourable  to  brain  nutrition,  for  the  brain  is  supplied  with 
more  blood,  the  strain  on  the  nervous  system  is  relaxed,  and 
the  mind  is  refreshed. 

The  amount  of  education  to  be  prescribed  should  be  deter- 
mined by  the  particular  case,  the  power  of  attention,  activity 
and  retentiveness  of  memory,  the  absence  of  unfavourable 
nerve  signs,  and  the  state  of  the  patient's  health.  Some 
boys  may  be  allowed  at  first  to  get  through  one  year's  average 
work  in  two,  three,  or  four  years. 

The  question  of  the  medical  inspection  of  schools  and 
school  children  need  not  be  discussed  here.  Our  great 
public  schools  for  the  upper  classes  have  their  medical 
officers,  and  their  value  as  factors  in  our  educational  system 
is  undoubted.  That  a  general  system  for  the  whole  country 
is  necessary  has  been  apparent  to  many  authorities  for  some 
time,  and  that  it  will  be  an  accomplished  fact  sooner  or  later 
is  a  reasonable  anticipation. 


CHAPTER  XIX. 

IDIOCY  AND  IMBECILITY. 

T^tiology — Syphilis  an  insignificant  cause— Alcoholic  influence  vaguely 
determined — Various  causes  and  conditions  with  which  it  is  associated 
—  Scrofula — Phthisis — Insanity — Epilepsy  very  potent — Pre-natal — 
Parturient  and  post-natal  influences  —  The  diagnosis  of  idiocy  and 
imbecility — Order  and  method  of  clinical  examinations — Ireland's 
classifications  :  (i)  Genetous  idiocy ;  (2)  microcephalic  idiocy ; 
(3)  eclampsic  idiocy  ;  (4)  epileptic  idiocy  ;  (5)  hydrocephalic  idiocy  ; 
(6)  paralytic  idiocy  ;  (7)  cretinism  ;  (8)  traumatic  idiocy  ;  (9)  inflam- 
matory idiocy  ;  (10)  idiocy  by  deprivation — Other  types  :  Mongolian, 
negroid,  etc. — Treatment  of  idiocy  and  imbecility  :  Medical,  surgical, 
institutional — The  last  embraces  three  factors  :  Hygiene,  administra- 
tive discipline,  education  in  school  and  workshop — The  course  of 
proceeding  necessary  in  order  to  place  an  idiot  or  imbecile  in  a 
special  training  school  or  lunatic  asylum. 

From  what  has  been  said  in  the  preceding  chapter,  it  must 
be  apparent  that  there  are  infinite  gradations  in  mental 
deficiency,  and  that  no  definition  can  precisely  isolate  idiocy 
from  imbecility,  and  in  turn  imbecility  from  feeble-minded- 
ness.  Seguin's  definition  of  idiocy,  in  his  work  pubHshed 
in  1846  on  the  moral  treatment,  hygiene,  and  education  of 
idiots  and  other  backward  children,  was  thus  expressed : 
'  An  infirmity  of  the  nervous  system,  which  has  for  its  effect 
the  abstraction  of  the  whole  or  part  of  the  organs  and  the 
faculties  of  the  child  from  the  normal  action  of  the  will.' 

Idiocy  and  imbecility  are  conditions  implying  different 
degrees  of  intellectual  growth,  and  moral  and  emotional 
development,  and  when  either  term  is  used,  it  is  understood 
that  the  mental  sum-total  is  minus  or  plus  according  as  the 
case  is  one  of  idiocy  or  imbecility.  The  forms  and  complica- 
tions are  endless  in  their  diversity,  and  in  order  to  lead  up 


IDIOCY  AND  IMBECILITY  417 

to  a  fair  appreciation  of  the  subject,  it  may  be  well  at  the 
outset  of  our  observations  to  give  considerable  attention  to 
the  question  of  aetiology. 

Etiology  of  Idiocy  and  Imbecility. 

A  distinction  has  been  drawn  between  causation  operating 
prior  to  birth,  at  birth,  and  during  infancy.  This  distinction 
is  open  to  fallacy,  because  of  the  obscurity  which  involves 
the  family  and  maternal  history  in  many  cases.  It  is  how- 
ever, one  that  is  continually  forced  upon  us  in  practice. 
The  parents  do  not  wish  to  entertain  the  notion  that  there 
is  potential  idiocy  or  imbecility  in  either  line  of  family 
descent,  and  are  naturally  most  anxious  to  discover  a  post- 
natal, or  even  a  parturient,  explanation  of  the  arrested  develop- 
ment. It  is,  however,  the  duty  of  the  physician  to  satisfy 
himself  at  least  of  the  real  factors  in  the  causation,  if  at  all 
possible. 

The  more  the  aetiology  of  these  defects  is  studied,  the 
more  evident  it  becomes  that  a  very  nice  discrimination  is 
necessary  in  order  to  apportion  to  each  factor  its  pathogenetic 
share  in  the  matter.  The  causes  of  idiocy  and  imbecility 
are  most  numerous,  and  many  which  we  might  a  priori 
consider  as  of  grave  potency  are,  after  the  careful  observa- 
tions of  several  competent  observers,  found  not  to  be  so. 
It  may  be  by  reason  of  deficient  famil}^  histories,  but  syphilis 
and  alcoholic  excess  do  not  occupy  a  prominent  place  in 
the  table  of  causation.  Shuttleworth,  Fletcher  Beach,  and 
Langdon  Down  are  agreed  that  there  is  as  yet  no  evidence 
recorded  that  syphilis  contributes  its  influence  in  more  than 
2  per  cent,  of  the  cases.  This  is  probably,  for  obvious  reasons, 
an  under-estimate. 

Intemperance  has  been  combined  with  many  causes,  in 
some  cases  as  many  as  five  or  six.  How  can  we  estimate 
its  influence  amidst  so  many  ?  The  conjoint  observations 
of  Shuttleworth  and  Fletcher  Beach  (Tuke's  '  Dictionary  of 
Psychological  Medicine  ')  made  on  1,180  cases  taken  from 
the  Darenth  Asylum  case-books  show  '  that  intemperance 
was  combined  in  ig6  with  the  following  causes  :  Phthisis, 
insanity,    imbecility,    epilepsy,    syphilis,    consanguinity,    ex^ 

27 


4i8  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

citability,  chronic  neuralgia,  abnormal  conditions  of  the 
mother  during  pregnancy,  premature  labour,  disease  of  the 
brain,  and  paralysis.'  This  gives  i6"8  per  cent.  ;  but  when 
to  this  is  added  the  further  analysis  that  '  intemperance  was 
combined  with  one  cause  in  ninety  cases,  the  most  frequent 
associations  with  it  being  insanity,  epilepsy,  phthisis,  and 
worry  of  the  mother  during  pregnancy,'  it  is  clearly  demon- 
strated that  i6*8  per  cent,  is  too  high  an  estimate  for  in- 
temperance per  se.  Further  examination  of  the  subject 
shows  that,  in  proportion  to  the  number  of  other  causes, 
intemperance  increases  in  its  percentage  as  factor,  though 
the  potency  must  correspondingly  diminish  as  a  general  rule. 

A  phthisical,  epileptic,  or  insane  family  history  bulks  more 
largely  in  the  causation  of  idiocy  and  imbecility,  and  the 
scrofulous  constitution  must  here  be  taken  as  counting  for 
a  great  deal  as  related  to  the  phthisical,  and  indicating  a  low 
state  of  general  nutrition  in  which  the  brain  must  participate. 
On  this  subject  Ireland  writes  ('Idiocy  and  Imbecility'; 
London,  J.  and  A.  Churchill)  :  'Perhaps  two-thirds,  or 
even  more,  of  all  idiots  are  of  the  scrofulous  constitution. 
No  physician  of  any  experience  could  fail  to  notice  this  on 
going  amongst  a  number  of  idiots.  The  greater  part  of  the 
work  which  falls  upon  the  doctor  of  a  training-school  for 
imbeciles  consists  in  the  treatment  of  the  different  local  and 
general  manifestations  of  the  scrofulous  diathesis,  such  as 
enlarged  or  suppurating  glands,  skin  eruptions,  ophthalmia, 
otorrhcea,  strumous  ulcers  and  abscesses,  and  fully  two- 
thirds  of  all  idiots  die  of  phthisis.' 

The  influence  of  heredity  is  undoubted,  whether  the  stock 
from  which  the  idiot  or  imbecile  springs  be  strumous, 
phthisical,  epileptic,  paralytic,  insane,  or  imbecile.  These 
conditions  may  be  interchangeable  in  the  same  family  tree. 
The  influence  of  consanguinity  has  been  very  much  disputed 
as  a  cause  of  hereditary  disease  apart  from  idiocy  and 
insanity  altogether,  and  the  statistics  published  which  at  all 
bear  upon  the  problem,  so  far  as  idiocy  and  imbecility  are 
concerned,  do  not  appear  to  be  conclusive.  The  fault  lies 
in  the  method  of  statistical  investigation  pursued.  Special 
tables  are  usuall}''  approximately  correct  so  far  as  they  go, 


IDIOCY  AND  IMBECILITY  419 

but   they   require  to    be   compared   with  general  conditions 
which  are  too  often  assumed  or  inaccurately  estimated. 

The  health  and  habits  of  the  parents  may  naturally  be 
expected  to  have  some  relation  to  the  mental  result  in  the 
offspring,  but  here  also  there  is  a  M'ant  of  unmistakable 
authority.  The  drunkenness  of  the  father  during  the  act 
of  procreation  has  been  assigned  as  a  cause.  When  we 
consider  how  often  this  must  occur,  considering  the  wide 
distribution  of  drinking  habits,  and  how  small  the  percentage 
of  idiocy  from  all  causes  is,  one  should  be  guarded  in  alleging 
against  drunkenness  that  it  is  an  important  factor  in  this 
connection.  The  relative  ages  of  the  parents  has  been  dis- 
cussed as  a  subject  bearing  on  this  inquiry.  Great  disparity, 
especially  when  one  parent  approaches  the  climacteric,  has 
been  regarded  as  a  condition  of  ill-omen.  According  to 
Shuttleworth  and  Fletcher  Beach  {op.  cit.),  '  the  old  age  of  the 
father  in  some  few  cases  seems  to  be  a  cause  of  idiotic  off- 
spring, and  the  "  Mongol  type  "  is  frequently  connected  with 
the  advanced  age  and  impaired  functions  of  the  mother,  more 
than  half  of  such  cases  being  the  last  children  of  a  long  family.' 

The  statement  of  Langdon  Down,  that  first  children  are 
affected  in  one-fifth  of  the  cases,  has  been  discounted  by  the 
fact  that,  as  pointed  out  by  Shuttleworth,  the  average  number 
of  a  family  may  be  five,  and  probably  is  not  more.  Illegitimacy, 
ill-health,  a  mental  disturbance  during  pregnancy,  falls,  or 
other  accidents  at  that  time,  and  various  other  pre-parturient 
causes,  have  been  adduced  and  enlarged  upon.  Of  mental 
disturbance  the  best  example  is  fright,  and  on  this  subject 
Ireland  observes  that  '  it  by  no  means  follows  that,  because 
we  can  indicate  a  predisposing  cause,  the  shock  to  the  mother 
could  not  have  been  the  exciting  one.  In  many  cases, 
hov/ever,  the  fright  is  the  only  apparent  cause.' 

Continuing,  he  observes :  '  I  do  not  think  we  are  entitled 
to  reject  such  explanations  merely  because  we  cannot  show 
how  the  shock  to  the  nervous  system  of  the  mother  can 
arrest  the  development  of  the  nervous  system  of  the  child. 
.  .  .  In  all  ages  women  have  believed  that  fright  or  extreme 
distress  are  dangerous  to  their  offspring,  and  I  see  no  reason 
for  denying  that  such  influences  during  pregnancy  may  in 

27 — 2 


420  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

some  cases  produce  idiocy  in  the  child  of  healthy  parents 
who  would  otherwise  be  born  free  from  mental  deficiency.' 
And,  again  :  '  Baron  Percy,  a  French  military  surgeon,  ob- 
served that  out  of  ninety-two  children  whose  mothers  had 
been  exposed  to  the  terrors, of  a  tremendous  cannonade  at 
the  siege  of  Landau  in  1793,  sixteen  died  at  the  instant  of 
birth  ;  thirty-three  languished  from  eight  to  ten  months,  and 
then  died  ;  eight  became  idiotic,  and  died  before  the  age  of 
five  years ;  and  two  came  into  the  world  with  numerous 
fractures  of  the  bones  of  the  limbs.' 

Of  parturient  causes,  almost  any  of  the  abnormal  develop- 
ments of  labour  might  be  cited  in  this  connection.  The  use 
of  instruments  has  been  stated  as  one  of  them,  but  there 
does  not  appear  to  be  sufficient  evidence  to  justify  this 
statement,  and  when  we  consider  how  frequently  instruments 
are  applied,  no  more  need  be  said.  With  the  use  of  instru- 
ments there  is  often,  however,  a  cause  which  frequently  calls 
for  such  interference,  and  this  is  more  likely  to  have  serious 
effect  on  the  head  and  brain,  viz.,.  tedious  or  difficult  labour. 
There  are  here  two  effects  at  work — prolonged  pressure  on 
the  head,  and  irregular,  insufficient  nutrition  of  the  child 
during  labour.  Asphyxia  neonatorum  was  given  in  153  of 
Dr.  Beach's  histories,  a  proportion  of  I2'g6  per  cent.  ;  but 
to  this  must  be  added,  and  it  emphasizes  the  importance 
of  this  cause,  that  labour  was  tedious  or  difficult  in  322  cases, 
or  about  25  per  cent.  The  figures  for  asphyxia  neonatorum 
are  probably  therefore  an  under-estimate. 

It  is  scarcely  necessary  to  say  that  premature  birth  is 
not  a  favourable  condition  to  start  life  with.  It  has  been 
stated  in  America  that  attempts  to  procure  abortion  are 
frequently  attended  with  this  result  that  idiocy  is  induced. 
In  so  far  as  the  induction  of  premature  labour  is  sure  to 
give  the  child  a  very  unfavourable  start  in  life,  and  the  fact 
that  mental  causes  to  account  for  this  malpractice  are  un- 
favourable to  the  intra-uterine  life  of  the  foetus,  it  is  quite 
conceivable  that  idiocy  should  result  therefrom. 

i\cquired  idiocy  or  imbecility  may  appear  at  any  time 
after  birth  as  a  result  of  causes  operating  during  the  years  of 
infancv  and  childhood.     Great  stress  has  been  laid  on   the 


IDIOCY  AND  IMBECILITY  421 

crises  of  dentition  as  times  of  anxiety  in  this  respect,  but  the 
range  of  possible  causes  that  may  damage  the  young  and 
tender  nervous  system  in  the  first  years  of  hfe  is  a  very  wide 
one.  The  infant  or  child  is  to  a  very  large  extent  a  reflex 
organism,  even  when  the  first  evidences  of  volition  have 
appeared,  and  the  sensori-peripheral  nerve-endings,  each  of 
them  excitable  on  very  slight  provocation,  are  so  numerous 
that  the  sources  of  irritation  cannot  be  reckoned.  Thus, 
tremors,  spasms,  convulsions,  are  quite  possible  in  any  child, 
and  when  disease  affects  it,  the  nervous  system  is  most  liable 
to  suffer. 

It  may  be  taken  that  the  following  conditions  considered 
seriatim  give  a  fair  resume  of  what  may  account  for  acquired 
idiocy  or  imbecility.  Convulsions  take  a  first  place,  though 
many  children  suffer  from  them  at  certain  crises,  especially 
during  dentition,  and  neither  become  epileptic  nor  idiotic 
after.  The  fact,  however,  that  a  child  has  had  convulsions 
is  a  stigma  in  its  history,  that  should  cause  the  family 
physician  to  inquire  very  carefully  as  to  its  after-develop- 
ment, and  advise  great  caution  in  its  treatment  physically 
and  mentally.  Sunstroke  or  heatstroke  may  in  a  few 
instances  be  credited  with  the  production  of  idiocy,  but 
parents  anxious  for  the  mental  integrity  of  the  family  stock 
may  make  too  much  of  this. 

Falls,  especially  on  the  head,  are  also  a  favourite  explana- 
tion ;  but  children's  falls  are  so  frequent,  so  much  the  rule, 
that  very  circumstantial  evidence — medical  preferred — would 
be  necessary  to  permit  of  this  explanation  being  accepted. 
Various  cerebral  affections,  inflammatory,  paralytic,  acute 
hydrocephalic,  etc.,  epilepsy,  fevers,  including  the  exanthe- 
mata, are  important  causes  of  idiocy  and  imbecility. 

The  Diagnosis  of  Idiocy  and  Imbecility. 

The  diagnosis  may  appear  to  be  a  simple  matter,  and  in  a 
general  way  this  is  so  ;  but  when  we  have  to  put  the  ques- 
tion to  ourselves.  Why  so  ?  or  when  we  have  to  give  evidence 
in  a  doubtful  case,  it  is  well  to  establish  clearly  our  points  of 
diagnosis,  and  the  "data  on  which  we  rest  our  opinion.  It 
may  be  necessary  to  establish,  not  only  the  fact  of  idiocy, 


422  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

but  also  the  fact  of  its  congenital  origin ;  for  in  cases  of  dis- 
puted pauper  settlement  this  latter  question  is  sure  to  arise. 

\'\'hen  a  reputed  or  doubtful  case  comes  under  notice, 
the  external  appearances  are  the  first  to  attract  notice.  We 
are  struck  perhaps  by  defects  of  development  :  the  patient  is 
short  and  dwarfed,  or  there  is  asymmetry  of  form,  perhaps 
spinal  curvature  or  club-foot.  He  may  be  incapable  of  pro- 
gression, except  on  all  fours,  just  like  an  average  child  of 
nine  or  ten  months.  If  he  is  able  to  walk,  there  may  be  a 
looseness  in  his  gait,  a  slouching  or  stooping  form,  or  there 
may  be  noticed  a  slow,  leaden  gait,  or  a  running  locomotion 
not  unlike  what  we  sometimes  see  in  old  men.  There  may, 
however,  as  in  non-congenital  cases  particularly,  be  none  of 
these  defects. 

The  form  of  the  head  and  the  facial  features  may  next 
attract  notice.  There  is  scarcely  a  conceivable  defect  that 
may  not  be  noticed  in  this  class.  So  much  has  been  written 
on  the  subject  already  that  we  must  here  glance  rather 
summarily  over  it,  throwing  perhaps  fresh  side-lights  on  it 
by  the  way.  The  shape,  size,  and  symmetry  of  the  head  are 
to  be  examined ;  the  growth  of  hair,  which  may  be  thin  and 
harsh,  and  the  contiguity  of  the  eves,  for  in  some  they  are 
too  close,  in  others  too  far  apart.  Other  e3'e  defects, 
strabismus,  etc.,  should  be  looked  for  ;  the  size  and  formation 
of  the  ears,  and  any  nasal  defect,  such  as  depression,  are 
important.  In  the  idiot  and  imbecile  the  mouth  gives 
striking  indications,  and  as  so  much  has  been  written  in  the 
previous  chapter  regarding  them,  it  will  suffice  to  say  that 
the  form  of  the  jaws  and  palate,  the  dental  arrangement,  and 
the  character  of  the  teeth,  ought  to  receive  attention.  The 
'  open  mouth,'  the  lips  apart,  and  saliva  dribbling  over,  are 
noteworthy  signs. 

The  size  and  power  of  the  limbs  is  also  a  diagnostic  point, 
and  the  grip  of  the  hands  should  be  tested.  Some  idiots 
have  no  more  prehensile  power  than  an  infant  of  six  months, 
and  as  a  rule  many  are  more  or  less  deficient  in  this  respect. 
The  muscular  movements  should  be  studied,  the  coarse  and 
fine  ones,  and  here  it  will  be  found  to  what  extent  co-ordi- 
nation has  developed. 


IDIOCY  AND  IMBECILITY  425 

The  state  of  the  circulation  and  the  other  vegetative 
systems,  and  the  general  nutrition  as  a  whole,  should  next 
be  examined.  The  circulation  is  often  feeble,  the  extremities 
cold  and  cyanotic,  and  there  is  a  tendency  to  chilblains. 

The  mental  examination  is  naturally  the  crux  of  the 
matter,  for  many  of  the  foregoing  signs  may  be  attended  with 
fair 'mental  development.  Taking  as  data  to  guide  us  what 
average  results  we  might  expect  in  a  child  of  the  same  age^ 
we  examine  accordingly.  It  may  however  be  evident  at  the 
very  outset,  that  we  must  begin  much  lower  down  ;  but  one 
caution  must  be  given.  Do  not  indulge  in  foregone  con- 
clusions because  of  anything  grotesque  or  repulsive  in  the 
appearance  or  manner  of  the  patient.  A  student  of  idiocy 
finds  before  very  long  that  here  appearances  are  more  than 
usually  deceptive. 

In  approaching  the  mental  study  of  such  a  case,  the  first 
thing  we  try  to  do,  as  a  matter  of  course,  is  to  attract 
attention,  and  this  we  may  find  it  very  difficult  to  do.  In  a 
very  young  infant  there  is  no  attention  to  arrest ;  as  it  gets 
older,  the  attention  flits  from  point  to  point,  and  may  be 
arrested  only  for  a  moment.  At  all  events,  it  is  easily  dis- 
tracted. You  may  find  any  of  these  conditions  in  the  idiot, 
and  you  may  find  still  more,  for  the  attention  may  be 
arrested  for  so  long  a  time  that  observation  and  some- 
amount  of  education  are  possible. 

Having  fixed  his  attention  and  asked  a  question,  you 
estimate  the  result.  Has  he  understood  what  was  said  ? 
If  not,  is  he  deaf,  or  is  his  faculty  of  language  defective  ?  If 
the  latter,  we  may  next  try  the  language  of  signs  and  expres- 
sion, just  as  we  do  with  infants,  and  it  is  probable  that  these 
may  convey  some  meaning  to  his  brain.  If,  however,  the  boy 
answers,  we  know  that  the  question  has  reached  him,  and 
according  to  the  answer  we  judge  to  some  extent  of  his 
intelligence,  and  of  the  faculty  of  speech.  It  may  be  absent 
owing  to  congenital  deafness,  or  it  may  be  owing  to  mental 
deficiency;  the  cause  may  be  motor.  It  may  be  slow,  delayed, 
guttural.  The  voice  may  be  pleasant  or  unpleasant,  harsh, 
or  croaking.  His  knowledge  can  now  be  tested,  his  memory, 
his  arithmetic,  and  his  moral  sense.     The  examination  may 


424  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

result  in  negatives  and  disappointments,  but  in  the  case  of 
imbeciles  there  are  many  encouraging  points  observed. 

The  other  special  senses  should  be  examined.  Objects 
placed  before  the  eyes  will  test  sight,  and  suggest  questions 
to  further  test  knowledge  and  mental  capacity.  In  the  same 
way,  with  the  eyes  closed,  touch  may  be  tested  and  questions 
asked.  In  all  these  tests  we  have  further  opportunities  of 
observing  how  far  the  patient  has  acquired  a  memory  of 
words,  and  with  what  facility  he  expresses  himself.  Some 
repeat  words  without  meaning.  Others  get  to  the  first  stage 
of  speech,  names  only,  while  not  a  few  can  form  sentences, 
and  express  their  meaning  in  simple  language. 

The  emotions  and  the  moral  character  often  exhibit  per- 
version or  defect  ;  usually  what  seems  perversion  is  explained 
by  defective  intelligence  and  inhibition.  The  emotion  of 
fear  is  excited  on  the  very  slightest  provocation  ;  anger  in 
many  idiots  comes  in  childish  passionate  explosions.  Some 
idiots  are  really  dangerous,  not  so  much  because  of  their 
strength  as  their  moral  recklessness.  They  do  not  merely 
bite,  stamp,  swear,  and  throw  things,  but  cruel,  homicidal, 
fire-raising  acts  may  be  committed  by  them  without  know- 
ledge or  fear  of  consequences.  Self-will  and  obstinacy  are 
very  common,  and  cunning — very  transparent  in  some  cases 
— is  frequently  observed.  Many  idiots,  having  been  in 
mischief  of  some  sort,  reveal  the  fact  before  it  is  suspected, 
by  making  groundless  accusations  against  others.  The 
most  destructive  case  I  have  known  committed  his  ill  deeds 
with  such  cunning  and  secrecy  that  he  was  often  un- 
suspected, until  he  gave  himself  away  by  accusing  someone 
else. 

Destructiveness  is  a  habit  which  we  naturally  expect  to 
find,  at  least  in  some  idiots,  and  all  the  mischief  of  which 
a  boy  is  capable  may  be  expected,  the  nature  of  the 
mischief  being  in  accordance  with  the  degree  of  intelligence 
reached.  Destructive  habits  are  seen  in  many  ways.  One 
has  a  penchant  for  breaking  glass,  another  for  tearing  clothes 
or  pulling  out  his  own  hair.  The  common  sensibility  in 
such  a  case  is  much  impaired.  One  such  patient  was  only 
restrained  by  the  threat  that  his  new  clothes,  which  were  very 


IDIOCY  AND  IMBECILITY  425 

gay  and  loud  in  tone,  would  be  taken  away,  and  he  wore  a 
soldier's  red  coat  for  a  year  without  destroying  it.  He  must 
retain  the  extravagant  instincts  of  some  progenitor,  perhaps 
a  beau  of  the  olden  time,  for  when  his  clothes  become  soiled, 
he  tears  them  because  he  cannot  cast  them  off. 

Some  idiots  and  imbeciles,  on  the  other  hand,  are  placid, 
lethargic,  or  gentle  and  amenable.  They  often  give  evi- 
dence of  an  affectionate  disposition,  but  have  strong  dislikes. 
Many  are  musical  in  a  primitive  way,  and  it  is  quite  common 
to  meet  with  idiots  who  can  hum  or  whistle  a  tune  which  they 
have  only  heard  once  before.  They  are  often  humorous, 
funny,  mischievous,  and  fond  of  tricks.  Their  mimicry  leads 
to  their  acquiring  bad  habits  rather  than  good  ones,  unless 
they  are  well  looked  after  in  a  training-school  for  this  class. 

Sexually  the  male  idiot  is  generally  agamous  as  regards 
function,  and.  the  female  idiot  is  usually  sterile.  Yet  in- 
stances are  not  rare  of  such  women  having  children. 

It  is  rather  a  difficult  matter  to  classify  idiocy  into  groups 
which  are  distinctive  in  their  causation,  physical  stigmata, 
and  mental  characters.  This  is  what  one  would  naturally 
aim  at ;  but  in  default  of  this  ideal,  we  must  accept  the  best 
compromise  possible.  A  great  many  types  have  been  named 
and  described ;  but  for  simplicity  and  practical  advantage 
the  classification  of  Ireland  is  probably  the  best,  and  the  one 
most  likely  to  represent  the  cases  usually  met  with  in  general 
practice.  Reference  will  be  made  in  a  few  words  to  some 
types  not  included  in  this  classification,  which  to  a  large 
extent  is  founded  on  the  pathology  of  the  disease. 

Ireland's  classification  includes  ten  varieties.  These  are  : 
(i)  Genetous  Idiocy;  (2)  Microcephalic  Idiocy;  (3)  Eclampsic 
Idiocy ;  (4)  Epileptic  Idiocy ;  (5)  Hydrocephalic  Idiocy ; 
(6)  Paralytic  Idiocy ;  (7)  Cretinism  ;  (8)  Traumatic  Idiocy ; 
•(g)   Inflammatory  Idiocy  ;   (10)   Idiocy  by  Deprivation. 

I.  Genetous  Idiocy.  —  This  term  has  been  employed  to 
■enclose  a  group  which  are  not  the  only  congenital  cases — 
for  microcephalic,  hydrocephalic,  and  other  forms  may  be 
congenital  also — but  which,  being  congenital,  have  no  other 
•distinguishing  causation  and  no  uniform  pathology.  Ireland 
regards  the  keel-shaped,  or  as  it  is  also  called,  the  saddle- 


426  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

shaped  palate  as  a  very  common  correlation  or  accom- 
paniment of  genetous  idiocy,  in  this  respect  giving  a 
distinction  between  genetous  and  microcephalic  idiocy,  for 
in  the  latter  the  palate  is  rarely  saddle-shaped. 

Having  regard  to  the  various  causes  which  may  patho- 
logically account  for  genetous  idiocy,  the  class  must  be 
regarded  as  rather  mixed  ;  but  certain  general  characters 
may  be  noticed.  There  is  defective  physique,  in  size  and 
qualit}',  a  feeble  circulation,  and  a  sensory  dulness.  In  some, 
however,  the  physical  development  is  very  fair,  although  men- 
tall}-  the  defect  is  extreme. 

2.  Microcephalic  Idiocy. — Here  one  would  a  priori  expect 
to  find  the  lowest  depths  of  idiocy,  but  it  is  not  always  so. 
Size  and  quality  are  two  totally  different  things,  and  in 
these  little  heads  of  microcephalic  idiocy  it  is  remarkable 
how  much  intelligence  and  education  is  sometimes  possible. 
While  this  is  so,  the  brain  may  diminish  almost  to  vanishing- 
point,  and  there  must  be  a  minimum  size  compatible  with 
normal  intellect,  even  if  we  are  unable  to  determine  it 
precisely,  and  are  forced  to  impose  an  arbitrary  cranial 
circumference  as  the  dividing-line. 

Two  lines  of  head  measurement  were  adopted  by  Voisin, 
and  to  these  he  attached  minimum  measurements.  He  re- 
garded intellectual  development  as  impossible  with  a  head 
from  II  to  13  inches  in  circumference,  and  a  measurement 
from  the  root  of  the  nose  to  the  posterior  border  of  the- 
occipital  bone  of  8  to  9  inches.  This  is  much  below  that 
given  by  the  London  Committee,  and  certainly  errs  in  an 
opposite  direction ;  but  Voisin  so  far  corrects  himself  in  the 
following  statement :  '  that  heads  from  14  inches  to  17  inches 
in  circumference,  and  from  11  to  12  inches  for  the  arc  com- 
prised between  the  root  of  the  nose  and  the  foramen  magnum, 
are  too  small  for  ordinary  intelligence  '  (Ireland,  op.  cit.).. 
These  latter  measurements  really  include  to  a  considerable 
extent  what  are  known  as  microcephalic  idiots. 

As  with  the  head,  so  with  the  body — it  is  stunted ;  but  as 
to  other  characters  there  may  be  much  diversity.  Though 
some  are  bright,  lively,  restless,  and  moderately  intelligent, 
and  to  some  extent  educable,  others  are  negative  in  almost 


IDIOCY  AND  IMBECILITY  427 


all  respects,  neither  walking,  speaking,  nor  showing  any  sign 
of  intelligence.     This  form  of  idiocy  is  rare. 

3.  Edampsic  Idiocy. — The  natural  dread  of  eclampsia 
which  mothers  experience  is  due  not  only  to  the  alarming 
symptoms  themselves,  and  the  possibly  fatal  result,  but  in 
part  to  the  fear  that  epilepsy  or  idiocy  may  supervene.  The 
chief  risk,  however,  is  the  immediate  one,  that  of  death,  for 
in  a  very  large  proportion  of  cases  eclampsia  is  neither 
followed  by  epilepsy  nor  idiocy.  While  usually  excited  by 
dentition,  it  may  come  on  earlier ;  but  at  whatever  time,  the 
possibility  of  brain  damage  resulting  must  not  be  disregarded. 
Two  unfavourable  results  are  possible — epilepsy  and  idiocy. 
Eclampsic  idiocy  is  to  be  distinguished  from  epileptic  idiocy 
by  the  fact  that  in  eclampsic  idiocy  the  convulsions  pass 
away,  and  only  the  brain  damage  remains  to  retard  mental 
development. 

The  prognosis  given  by  Ireland  in  such  cases  is  unfavour- 
able :  '  Though  the  power  of  muscular  motion  as  well  as  the 
tactile  sensibility  is  generally  well  preserved,  and  special 
sense  does  not  appear  to  be  injured,  the  intelligence  is  in 
a  great  degree  destroyed,  and  the  child  remains,  compara- 
tively speaking,  uneducable.  He  can  be  taught  more  readily 
to  work  than  to  think.' 

4.  Epileptic  Idiocy. — Epilepsy  excited  by  dentition  or  in- 
dependent of  it  may  occur  during  any  part  of  childhood, 
and  from  what  has  been  written  in  the  chapter  on  epileptic 
insanity,  on  the  influence  of  this  neurosis  on  the  mental 
condition,  it  will  be  understood  that  the  later  it  appears  the 
better.  Some  very  eccentric  epileptic  histories  have  been 
published,  and  some  very  remarkable  results.  It  is  a  moot- 
point  whether  the  epileptic  idiot  or  imbecile  is  a  good 
subject  for  educational  treatment  compared  with  other  types. 
It  is  true  that  many  who  take  one  step  forward  between  fits 
appear  to  go  two  backward  after  them,  but,  on  the  other 
hand,  many  cases  do  exceedingly  well,  and  may  pass  out  of 
idiocy  into  the  higher  states  of  imbecility. 

The  epileptic  idiot  is  in  some  respects  a  distorted  picture 
of  the  epileptic  lunatic ;  but  there  is  a  degenerate  condition 
which  has  no  counterpart,  as  a  rule,  in  epileptic   insanity. 


428  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

Irritability  here  also  is  the  keynote,  the  fury  and  passion 
being  if  possible,  more  vehement  and  outrageous.  The 
physique  and  strength  are  frequently  better  than  in  most 
idiot  types.  Keeping  in  view  that  epilepsy  is  not  uncommion 
without  mental  defect  or  disturbance,  we  ought  to  recognise 
the  fact  that,  unless  there  is  grave  cerebral  impairment,  the 
process  of  education  may  go  on  safely  at  a  slow  pace.  The 
fits  are  the  obstacle  in  many  cases,  and  the  more  frequently 
they  occur,  the  more  frequent  must  be  the  interruptions  of 
the  educational  course. 

Much  may  be  hoped  for  by  successful  dieting  and  hygienic 
treatment.  The  usual  rules  of  hygienic  treatment  apply  to 
the  epileptic.  The  diet  should  be  non-stimulating,  and  only 
a  little  nitrogenous  food  given.  Where  scrofula  and  the 
phthisical  tendency  are  so  predominant,  though  they  affect 
the  epileptic  less,  perhaps,  than  other  classes,  cod-liver-oil 
should  be  freely  given.  In  bromide  of  potassium  we  have  a 
remedy  that  by  judicious  use  will  lessen  the  number  of  the 
fits,  and  thus  afford  longer  free  spells,  during  which  education 
may  make  decided  progress. 

5.  Hydrocephalic  Idiocy. — This  form  requires  to  be  distin- 
guished from  the  large  head  of  rickets,  in  which  the  anterior 
fontanelle  is  depressed  and  the  head  is  elongated.  In  the 
hydrocephalic  type  we  may  have  imbecility  as  frequently  as 
idiocy,  for  the  hydrocephalic  condition  varies  in  its  position, 
■degree,  pressure,  and  cerebral  effects.  It  is,  moreover, 
astonishing  that,  even  in  cases  of  great  brain  destruction 
and  arrested  development,  relatively  large  mental  results 
are  possible. 

In  the  Journal  of  Mental  Science  (October,  1879)  I  published 
a  paper  entitled  '  A  Detached  Left  Occipital  Lobe,  and  other 
Abnormalities  in  the  Brain  of  a  Hydrocephalic  Imbecile.' 
Within  the  cranium  were  found  three  cysts  containing 
38  ounces  of  fluid.  Several  convolutions  were  destroyed; 
there  was  almost  entire  absence  of  the  corpus  callosum,  and 
the  left  occipital  lobe  had  no  functional  connection  with  the 
rest  of  the  brain,  except  a  nutritive  one.  It  was  of  foetal  size,  and 
was  attached  to  the  main  brain  by  a  mere  strip  of  pia  mater. 

The  patient  lived  to  the  age  of  forty-one ;   he  was  illegiti- 


IDIOCY  AND  IMBECILITY  429 


mate,  and  had  been  utterly  neglected.  He  was  born  hydro- 
cephalic and  hemiplegic,  and  all  his  life  was  deformed  and 
helpless.  Incapable  of  progression  in  the  ordinary  manner, 
he  had  been  accustomed  to  move  about  for  short  distances 
on  all  fours,  and  while  in  the  asylum  required  to  be  carried 
about  from  place  to  place. 

The  measurements  were  :  height  4  feet  6  inches ;  circum- 
ference in  the  plane  of  the  nipples  2gf  inches ;  circumference 
in  the  plane  of  occipital  protuberance  and  frontal  eminences 
24I  inches.  The  palate  was  saddle-shaped,  the  pommel 
well  marked  ;  there  were  no  molars  in  the  lower  jaw,  and 
only  one  in  the  upper.  There  were  no  canines  or  bicuspids 
in  the  upper  jaw. 

The  sight  was  myopic,  and  convergent  strabismus  of 
the  right  eye  existed.  Hearing  and  taste  were  unimpaired. 
The  best  -  developed  faculty  was  memory,  and  the  most 
exaggerated  was  fear ;  thunder,  a  bath,  or  being  placed  in 
a  chair,  terrified  him.  He  was  afraid  of  falling  even  when 
safely  secured  in  an  armchair.  He  could  not  read,  simply 
because  he  had  never  been  taught,  not  because  he  wanted 
memory  or  a  fair  share  of  comprehensive  power,  for  he  pos- 
sessed both. 

This  was  a  case  of  hydrocephalus  with  imbecility  ;  but  a 
second  may  be  briefly  noted,  which  shows  extreme  idiocy 
sans  intellectual  faculties,  except  of  the  most  rudimentary 
kind.  He  is  a  boy  of  fourteen  years  of  age,  48  inches  in 
height,  with  26  inches  circumference  in  the  plane  of  the 
nipples,  and  22I  inches  circumference  of  the  head.  We 
have  a  syphilitic  history  of  his  case,  and  we  have  evidence  of 
congenital  syphilis  in  the  patient  himself,  in  the  cachexia,  the 
fissures  round  the  mouth  and  extending  well  over  the  cheeks, 
and  the  state  of  the  teeth ;  the  upper  incisors  are  not  placed 
laterally,  but  two  in  front  of  the  others.  He  has  cataract  of 
both  eyes,  and  disease  of  the  right  hip-joint. 

This  boy  has  never  learned  to  walk ;  he  can  crawl.  He 
shows  very  little  sign  of  intelhgence,  though,  like  a  child,  he 
knows  when  his  food  is  brought  to  him ;  faculty  of  speech 
there  is  none,  but  he  makes  noises  like  a  child,  and  amuses 
himself  like  an  infant  a  year  old. 


430  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

6.  Paralytic  Idiocy. — Cases  arise  from  time  to  time  of 
pre-natal  or  post-natal  brain  lesion,  giving  rise  to  imperfect 
development  and  paralysis,  usually  hemiplegia.  Other  forms 
of  paralysis,  spinal  as  well  as  cerebral,  occur,  and  sometimes 
with  the  latter  is  associated  epilepsy.  The  lesion  is  usually 
a  fixture,  and  does  not  extend,  so  that  the  rest  of  the  brain, 
being  unaffected  by  it,  may  develop  to  a  certain  extent. 
Cases  so  affected  are  frequently  imbeciles,  and  the  prospect 
educationalh'  is  fairly  good.  Some,  indeed,  may  be  more  or 
less  self-supporting. 

7.  Cretinism. — Notwithstanding  that  this  condition  is  rare 
in  this  country,  being  limited  to  goitrous  districts,  it  is 
interesting  setiologically,  and  especially  so  because  of  its 
relation  to  goitre  and  myxoedema.  It  is  found  to  exist  in 
close  valleys  in  the  Alps  and  elsewhere  on  the  Continent,  and 
is  frequently,  one  might  say  almost  invariably,  associated 
with  goitre,  though  some  cretins  do  not  appear  to  suffer 
from  goitre. 

The  physical  development  is  arrested,  so  that  many  are 
short  and  dwarfish  in  stature,  with  swollen  belly,  thick  neck, 
often  goitrous,  heavy  face,  and  stupid  expression.  The  eyes 
are  far  apart,  the  tongue  large,  and  the  lips  thick.  To  this 
description  there  are  exceptions,  because  there  are  many 
stages  and  varieties  of  cretinism,  and  cases  have  been  re- 
ported as  tall  as  6  feet. 

8.  Traumatic  Idiocy. — Ireland  distinguishes  betv/een  this 
and  inflammatory  idiocy  thus  :  '  Although  inflammation  is 
likely  to  follow  a  blow  on  the  head,  it  may  be  small  in 
comparison  to  the  damage  done  by  the  direct  injury  which 
the  brain  experiences  from  contusion,  incision,  division  of 
the  nervous  tissue,  or  depression  of  the  skull.'  The  distinc- 
tion here  drawn  is  one  rather  of  pathological  character  and 
extent  than  of  clinical  importance,  for  the  amount  of  mental 
defect  will  depend  on  the  extent  of  the  injury.  The  cases 
which  have  been  recorded  appear  to  show  that  imbecility  or 
weak-mindedness  is  the  worst  possible  result  in  such  cases. 
Careful  inquiry  should  be  made  as  to  the  precise  nature  and 
extent  of  the  accident,  and  it  is  well  to  ascertain  what  the 
personal  and  family  history  has  hitherto  been.     The  age  at 


IDIOCY  AND  IMBECILITY  431 

which  the  accident  occurs  is  also  of  importance,  for  in  cases 
a  few  years  old  the  mental  damage  is  less  than  if  the  same 
accident  happened  earlier.  At  the  same  time,  there  is  more 
resilience  in  the  younger  child,  and  a  less  untoward  result  in 
the  case  of  minor  accidents. 

g.  Inflammatory  Idiocy. — This  might  be  called  post-febrile, 
for  many  cases,  of  stupidity  at  least,  arise  after  measles, 
scarlatina,  etc.,  and  inflammation  of  the  middle  ear  may 
give  rise  to  it.  Ireland  is  rather  sceptical  on  this  point  ; 
but  in  general  practice  such  cases  are  sure  to  be  met  with. 
Inflammatory  idiocy  in  many  cases  however  is  really  a  sequel 
of  traumatism.  The  seat,  depth,  and  superficial  extent  must 
determine  the  mental  result,  and  therefore  no  clinical  descrip- 
tion of  this  group  is  possible,  for  there  may  be  every  possible 
gradation  and  variation. 

10.  Idiocy  by  deprivation  is  a  form  of  considerable  import- 
ance. The  loss  or  absence  of  one  or  more  senses  must 
necessarily  mean  the  occlusion  of  certain  avenues  to  the 
intelligence  department  of  the  mind,  and  in  this  form  of 
idiocy  we  usually  know  what  requires  to  be  made  up  in  the 
way  of  sensory  information,  so  as  to  bring  the  mind  as  near 
to  a  normal  standard  as  possible.  A  remarkable  case — the 
classic  case  on  record — was  that  of  Laura  Bridgman,  pub- 
lished by  the  late  Dr.  Howe,  of  Boston.  It  was  not  a  case 
of  idiocy,  or  even  imbecility,  and  it  established  two  important 
facts  :  First,  that  deprivation  of  senses  does  not  necessarily 
imply  brain  defect  or  mental  incompetence  ;  second,  that  by 
the  aid  of  one  sense  the  brain  can  be  stimulated,  the  mind 
exercised  and  developed,  and  a  remarkable  degree  of  know- 
ledge attained  to. 

Laura  Bridgman  was  a  perfectly  normal  child  for  the  first 
years  of  life.  As  a  result  of  scarlet  fever  she  lost  her  senses, 
except  touch  and  smell,  the  latter  however  being  impaired. 
Dr.  Howe  found  her  in  a  little  village  in  the  mountains,  a 
bright,  lively  child  of  six  years,  and  was  so  interested  in  her 
case  that  he  took  her  to  Boston  and  had  her  educated  by 
special  methods.  He  thus  describes  the  course  of  instruc- 
tion : 

'  I  required  her  by  signs,  which  she  soon  came  to  under- 


432  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

stand,  to  devote  several  hours  a  day  to  learning  to  use  her 
hands,  and  to  acquiring  command  of  her  muscles  and  limbs. 
But  my  principal  aim  and  hope  was  to  enable  her  to 
recognise  the  twenty-six  signs  which  represent  the  letters  of 
the  alphabet.  She  submitted  to  the  process  patiently,  but 
without  understanding  its  purpose.  ...  I  placed  before 
her,  on  the  table,  a  pen  and  a  pin,  and  then,  making  her  take 
notice  of  the  fingers  of  one  of  my  hands,  I  placed  them  in 
the  three  positions  used  as  signs  of  the  manual  alphabet  of 
deaf-mutes  for  the  letters  p  e  n,  and  made  her  feel  of  them, 
over  and  over  again,  many  times,  so  that  they  might  be 
associated  together  in  her  mind.  I  did  the  same  with  the 
pin,  and  repeated  it  scores  of  times.  She  at  last  perceived 
that  the  signs  were  complex,  and  that  the  middle  sign  of  the 
one — that  is,  the  e — differed  from  the  middle  sign  of  the  other 
— that  is,  i.  This  was  the  first  step  gained  '  (Ireland,  op.  cit.). 
The  process  thereafter,  though  slow,  was  steady,  and  she 
acquired  a  fair  measure  of  education,  and  in  her  own  sphere 
lived  to  good  purpose,  and  did  much  to  assist  in  the  educa- 
tion of  others  afflicted  like  herself,  though  not  to  the  same 
extent,  for  her  case  was  an  extreme  one.  It  must  not  be 
supposed  that  absence  of  any  of  the  senses  is  necessarily 
congenital,  or  even  frequently  so.  The  case  of  Laura 
Bridgman  and  many  others  prove  that  post-natal  conditions, 
inflammatory  or  febrile,  may  be  followed  by  the  loss  of  one 
or  more  senses.  At  the  same  time,  we  have  no  doubt  that  a 
weak  diathesis  has  been  subjected  to  the  inflammatory  or 
febrile  process,  often  a  scrofulous  one,  in  many  cases. 


Other  Forms  of  Idiocy. 

Mention  will  be  made  of  these  very  briefly,  for  it  is  un- 
necessary to  do  more  than  enumerate  some  so-called  types 
that  are  more  ethnological  in  their  interest  than  of  chnical 
or  practical  importance. 

Though  ethnological  in  its  nomenclature,  we  cannot  omit 
to  particularise  the  Mongolian  variety,  which  is  regarded  by 
Langdon  Down  as  very  characteristic  of  lo  per  cent,  of  idiocy. 
Regarding  them,  he  observes  that  '  the  members  of  this  class 


IDIOCY  AND  IMBECILITY  433 

are  often  the  latest  born  of  the  family,  and  are  connected  with 
a  phthisical  ancestry.  They  are  characterized  by  shortness  of 
stature,  their  heads  are  brachycephalic  (short-headed),  and 
there  is  often  a  remarkable  deficiency  in  the  posterior  part  of 
the  cranium.  Their  hair  is  usually  sparse  and  their  eyes 
obliquely  placed,  with  small  palpebral  fissures,  and  a  great 
distance  between  their  inner  canthi.  .  .  .  Their  tongues  are 
abnormally  long,  and  have  a  beefsteak  appearance.  They 
have  speech,  but  it  is  deferred,  and  always  of  a  guttural 
character,  .  .  .  They  are  very  grotesque,  see  the  humorous 
side  of  things.  .  .  .  They  are  all  characterized  by  strong 
self-will.  They  have  wonderful  imitative  power,  and  their 
love  of  mimicry  is  very  remarkable,  but  not  more  so  than 
their  persistent  obstinacy  '  (Tuke's  '  Dictionary'). 

Other  forms  of  idiocy  are :  (a)  Negroid,  or  Ethiopian,  of 
negro  type,  without  negro  ancestry,  even  the  most  remote  ; 
{b)  Malay  type ;  (c)  Caucasian  ;  [d)  Choreic ;  {e)  Hyper- 
trophic, due  to  hypertrophy  of  cerebral  white  substance,  or 
inflammatory  thickening  of  bones  and  fibrous  tissue ; 
(/)  Kalmuc,  resembling  Mongolian,  named  and  described  by 
Mitchell  and  Fraser. 


Treatment  of  Idiocy  and  Imbecility. 

It  may  be  accepted  as  an  axiom  that  the  treatment  of 
idiocy  and  imbecility  should  be  undertaken  in  a  special 
training-school  for  such  children.  Such  institutions  exist 
for  poor  and  rich,  and  an  elaborate  system  is  provided, 
graduated  to  meet  the  wants  of  individual  cases.  Seeing 
that  the  responsibility  for  such  treatment  does  not  lie  with 
the  general  practitioner,  it  is  merely  necessary  to  glance 
cursorily  at  the  main  principles  which  regulate  it.  Before 
doing  so,  however,  a  few  observations  are  necessary  on 
medical  and  surgical  treatment. 

Medical  treatment  may  be  pursued  with  a  view  to  im- 
proving the  general  health  and  strengthening  the  constitu- 
tion, and  in  these  respects  differs  not  from  the  usual 
treatment  of  scrofulous  and  anasmic  conditions.  Thyroid 
treatment,  with  a  specific  end  in  view,   has  been  tried  in 

28 


434  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

cretinous  cases  with  apparent  success ;  and  encouraging 
results  have  been  pubHshed  by  Sir  Frederick  Bateman  in 
the  second  edition  of  his  httle  book,  '  The  Idiot  :  his  Place 
in  Creation  and  his  Claims  on  Society,'  just  published. 

The  surgical  treatment  of  the  microcephalic  condition,  by 
means  of  craniectomy,  has  been  recommended  and  practised. 
The  reason  put  forward  for  this  is  that  premature  synostosis 
has  caused  the  arrest  of  brain  development  and  consequent 
brain  deficiency.  It  has  been  recommended  by  Lannalongue, 
Keen,  Horsley,  and  others ;  but  Bourneville  discourages  it, 
and  asserts  his  certain  knowledge,  founded  on  an  examination 
of  the  skulls  of  a  number  of  idiots,  that  premature  synostosis 
is  not  at  all  common.  These  opposing  views  leave  us  some- 
what in  the  dark,  and  this  operation  will  probably  be  under- 
taken where  the  risk  of  death  is  not  regarded  as  too  serious, 
although  the  operation  has  proved  fairly  safe  and  successful. 

The  means  of  treatment  in  institutions  are  hygienic,  ad- 
ministrative, and  educational.  It  needs  no  argument  to 
convey  the  truth  that  light,  fresh  air,  good  drainage,  good 
water,  and  attention  to  all  the  laws  of  health,  are  even  more 
important  for  the  well-being  of  the  idiot  than  any  other 
class.  The  position  and  surroundings  of  such  institutions, 
and  their  structural  arrangements,  are  only  determined  with 
these  objects  kept  in  view. 

The  administrative  arrangements  imply  order,  method, 
punctuality,  and  obedience.  This  discipline  is  good,  for  the 
young  especially,  and  most  of  all  for  the  idiot  who  is  erratic, 
wayward,  obstinate,  self-willed,  and  difficult  to  control  and 
regulate. 

The  educational  system  is  fixed  according  to  certain 
principles,  and  the  education  of  the  senses  by  object  lessons 
is  very  much  made  use  of,  and  has  a  reflex  influence  in  the 
education  of  the  mind.  Great  pains  are  taken  in  the  culti- 
vation of  speech,  in  some  cases  by  lip  exercise,  as  in  the  case 
of  deaf-mutes.  Attention  is  paid  also  to  moral  training  ;  and 
in  some  cases  hypnotic  suggestion  has  been  tried  (Voisin  in 
Revue  de  VHypnotisme,  November,  1888),  but  nothing  im- 
portant has  yet  resulted.  Various  trades  and  occupations 
have  been  taught  in  these  institutions,  and  some  who  are  not 


IDIOCY  AND  IMBECILITY 


435 


educable  in  the  ordinary  school  sense  make  decided  progress 
in  manual  or  other  employment,  and  may  in  after-years  con- 
tribute materially  to  their  own  support. 

The  Course  of  Procedure  necessary  in  order  to 
PLACE  AN  Idiot  or  Imbecile  in  a  Special  Train- 
ing-school OR  A  Lunatic  Asylum. 

To  place  an  idiot  or  imbecile  under  control  in  an  institu- 
tion registered  under  the  Idiots  Act,  1886,  is  a  much  more 
simple  process  than  to  place  a  person  under  control  in  a 
lunatic  asylum.  If  an  idiot  or  an  imbecile,  however,  is  to 
be  placed  under  control  in  a  lunatic  asylum,  and  not  in  an 
institution  registered  under  the  Idiots  Act,  1886,  the  same 
procedure  must  be  gone  through  as  if  he  or  she  were  an 
ordinary  lunatic. 

To  place  a  person  under  control  in  an  institution  registered 
under  the  Idiots  Act,  the  following  documents  must  be 
filled  up  : 


FORM  OF  MEDICAL  CERTIFICATE  FOR  ENGLAND. 

1  ,  the  undersigned,  , 

a  person  registered  under  the  Medical  Act,  1858,  and  in  actual  practice 
of  the  Medical  Profession,  certify  that  I  have  carefully  examined 

,*  an  infant  [or  of  full  age],  now  residing  at 
,  and  that  I  am  of  opinion  that  the  said 

is  an  Idiot  [or  has  been  an  Imbecile  from  birth, 
or  for  years  past,  or  from  an  early  age],  and  is  capable  of  receiv- 

ing benefit  from  [the  institution  (describing  it)],  registered  under  the  Idiots 

Act,  1896. 

Name 

Medical  Qualification 

Place  of  Abode 


Dated  this  day  of  One  thousand  eight 

hundred  and 

*  Erase  the  phrases  not  required. 

28—2 


436  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

FOR^I  OF  STATEMENT. 

If  any  partic^ilars  hi  this  Statement  be  not  knoivn^  the  fact  to  be  so  stated. 

Name    of    Patient,    with    Christian  "/ 
Name  at  length  -         -         -  ( 

Sex  and  Age    ----- 

When   and  where  previously  under  / 
Care  and  Treatment  -         -  \ 

In  any  Asylum  or  Institution    - 

Whether  subject  to  Epilepsy    - 

Whether  Dangerous  to  others 

I  certify  that,  to  the  best  of  my  knowledge,  the  above  particulars  are 
correctly  stated. 

Name 


Place  of  Abode  ^ 


[To  be  signed  by  the  Parent  or  Guardian  of  the  Idiot  or  Imbecile,  or 
the  Person  imdertaking  and  performing  towards  him  the  duty  of  the 
Parent  or  Guardian.] 

Here,  it  will  be  seen,  there  is  no  need  for  a  judicial  reception  order,  nor, 
in  fact,  anv  order  bevond  the  medical  certificate. 


FORM    OF    MEDICAL    CERTIFICATES 
FOR    SCOTLAND. 


MEDICAL  CERTIFICATE,  No.  i. 

1  ,  the  undersigned,  ^ 

do  hereby  certify  that  I  have  this  day  at  , 

in  the  county  of  ,  personally  examined 

,  and  believe  to  be  of  unsound  mind,  and  to  be 

capable  of  deriving  benefit  from  training  and  treatment  in  the  Institution 
for  the  Training  of  Imbecile  Children  at 

Name 

Medical  Qualification  

Place  of  Abode 


Datfj)  this  day  of  One  thousand  eight 

hundred  and 


FORM  OF  MEDICAL  CERTIFICATE  437 


FORM  OF  STATEMENT. 

If  any  of  the  particulars  in  this  Statement  be  not  known,  the  fact  to  be  so 

stated, 

1.  Christian   Name  and   Surname  of) 

Patient  at  length        -         -         -  j 

2.  Date  of  becoming  Chargeable 

3.  Sex  and  Age  - 

4.  Previous  Place  of  Abode 

5.  Place  where  Found  and  Examined 

6.  Whether  Imbecile  from  Birth 

7.  When  and  where  previously  under 

Examination  and  Treatment 

8.  Supposed  Cause    -         -         -         - 

9.  Whether    Deformed,    or    affected  \ 

with  Bodily  Disease  -         -         -  S 

10.  Whether  able  to  (i)  Speak     - 

(2)  Walk      -         - 

(3)  Dress  self 

(4)  Feed  self 

11.  Whether  subject  to  Epilepsy 

12.  Whether  Paralytic  .         .         - 

13.  Whether  of  Dirty  Habits 

14.  Whether  Noisy      -         -         -         - 

15.  Whether  Destructive     - 

16.  Whether  any  Relative  known  to  be  \ 

or  to  have  been  Insane      -        -  \ 

I  certify  that,  to  the  best  of  my  knowledge,  the  above  particulars  are 

correctly  stated. 

» 

Dated  this  day  of  One  thousand  eight 

hundred  and 

In  Scotland  two  Medical  Certificates  are  required,  and  the  sanction  of 
the  General  Board  of  Lunacy  must  thereafter  be  obtained. 

*  To  be  signed  by  the  Inspector  of  Poor  or  Other  Person  Interested. 


CHAPTER  XX. 

THE  LEGAL  AND  CIVIL  ASPECTS  OF  MENTAL  DISEASE— 
THE  FUNCTIONS  OF  MEDICAL  MEN  IN  RELATION  TO 
THESE. 

The  question  of  responsibility — The  amount  not  always  the  same  even  in 
the  same  individual  at  different  times — The  McNaughton  case  :  views 
on  criminal  responsibility  in  England  and  Scotland — Evidence  of 
lunatics — Certificates  of  insanity  with  a  view  to  asylum  treatment — 
Rules  to  guide  medical  men  in  granting  these — Law  as  to  the  treat- 
ment of  single  patients — Law  of  interference  with  a  lunatic's  property 
in  Scotland,  England,  and  Ireland  —  Certificates  of  testamentary 
capacity — Forms  in  use  in  England,  Scotland,  and  Ireland — Special 
home  treatment  for  inebriates. 

The  duties  of  medical  men  are  various :  their  mioral  obliga- 
tions are  not  few,  and  no  disease  draws  so  much  on  their 
time  and  attention  in  these  respects  as  mental  disease. 
The  reason  is  not  far  to  seek  ;  mental  disease  involves  the 
man  himself  in  the  fullest  sense  of  the  term.  It  raises 
questions  of  responsibility,  the  freedom  of  the  subject,  busi- 
ness capacity,  and  mental  competence  in  various  relations. 
The  question  brought  home  to  the  medical  man  is  not  one 
merely  of  the  individual  patient,  the  nature  of  his  disease 
and  how  best  to  treat  it  ;  but  how  it  affects  others,  how  it 
affects  life  and  property,  and  the  health  of  posterity. 

Responsibility. 

The  first  question,  that  of  responsibility,  is  a  very  wide 
one,  and  applies  to  many  circumstances  of  life.  All  sane 
men  and  women  are  responsible.  The  law  recognises  it,  the 
Church  affirms  it,  the  individual  himself  knows  it.  We 
cannot,    however,    dispute    the    statement    that    there   are 


LEGAL  AND  CIVIL  ASPECTS  OF  MENTAL  DISEASE    439 

degrees  of  responsibility,  especially  when  we  consider  that 
they  may  occur  as  the  result  of  disease,  and  particularly  as 
the  result  of  mental  disease. 

The  argument  has  been  advanced  that  the  man  who 
inherits  a  weak  self-control,  the  result  of  insanity  in  his 
ancestors,  should  be  excused,  if,  seized  by  an  impulse,  he 
commits  murder ;  that  the  man  who  inherits  a  gouty  organi- 
zation, and,  when  the  fit  is  on  him,  pitches  a  bootjack  at 
his  dearest  friend,  should  be  excused  if  he  puts  the  blame 
upon  his  father  ;  and  that  the  man  who  inherits  an  irritable 
stomach  may  not  be  wholly  responsible  if  he  relieves  himself 
of  his  irritability  in  a  torrent  of  abuse. 

Be  this  as  it  may,  we  would  like  to  make  excuses,  and  we 
are  aware  of  differences  in  ourselves  at  different  times — of 
periods  of  irresolution,  of  want  of  moral  courage,  of  excessive 
irritability,  and  greater  liability  to  yield  to  temptation.  We 
recognise  in  different  individuals  different  constitutions, 
having  temperaments,  passions,  cravings,  peculiar  to  them- 
selves. We  see  one  man  happily  placed,  so  that  the  sin  he 
would  do  under  other  circumstances  he  is  saved  from  com- 
mitting, because  there  is  no  temptation  to  do  so. 

The  question  of  responsibility,  as  a  definite  issue,  is 
brought  before  us  in  connection  with  crime  and  insanity. 
The  law  has  hitherto  been  very  chary  of  accepting  a  plea 
of  insanity  as  excusing  crime  ;  but  as  there  are  degrees  of 
insane  obliviousness  to  right  and  wrong,  degrees  of  self- 
control,  degrees  of  insane  impulse,  there  must  come  some 
day  a  general  recognition  of  the  fact  that  there  must  be 
degrees  of  responsibility  and  degrees  of  punishment. 

That  the  law  is  slow  to  recognise  this  is  not  surprising, 
seeing  that  a  tendency  to  ascribe  criminal  acts  to  insanity  is 
becoming  so  common.  Men  who  would  scout  the  idea  of 
having  insanity  in  their  families,  hug  the  notion,  search  the 
family  records,  strain  the  doctrine  of  heredity,  and  pro- 
claim the  culprit  insane,  if  he  happens  to  belong  to  them- 
selves. A  few  years  ago  a  young  man  who  shot  his  mother 
dead  was  sentenced  to  only  ten  years'  penal  servitude.  The 
plea  was  heredity  and  temporary  insanity.  This  is  a  grading 
of  responsibility,  and  is  a  step  towards  what  will  inevitably 


440  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

come  sooner  or  later.  Civilization  has  excuses,  and  public 
opinion— sometimes  unwise  and  hysterical — is  apt  to  be 
clamorous,  and  because  of  its  volume  and  importunity  is 
a  factor  of  considerable  weight. 

To  determine  responsibility  is  often  a  difficult  matter, 
and,  as  a  rule,  expert  testimony  is  required  ;  but  judges 
are  frequently  at  a  loss  when  expert  testimony  is  brought 
forward  for  both  sides  of  the  case,  and  naturally  suspicion 
arises  as  to  the  value  of  such  evidence.  It  comes  to  be, 
therefore,  that  the  common-sense  of  the  general  practitioner 
and  the  jury  are  as  much  relied  on  as  the  skill  and  fence  of 
the  specialist,  in  the  opinion  of  some  judges.  The  decisions 
that  have  been  given  in  the  present  century,  the  verdicts 
and  sentences,  reveal  a  gradual  enlightenment  of  the  legal 
mind,  and  an  increase  of  medical  influence  with  the  bench ; 
but  still  we  are  far  from  having  a  definite  legal  expression  of 
what  constitutes  responsibility,  and  a  differentiation  of  its 
degrees.  The  latter,  of  course,  is  a  very  difficult  thing  to 
determine — that  must  be  admitted ;  but  the  principle  of 
differentiation  should  be  approved. 

The  case  which  has  guided  many  decisions  in  the  last 
fifty  years  is  the  famous  McNaughton  case,  one  of  chronic 
delusional  insanity.  McNaughton  was  tried  for  the  wilful 
murder  of  Mr.  Edward  Drummond,  the  private  secretary  of 
Sir  Robert  Peel.  His  intention  was  to  kill  Peel,  and,  seeing 
Drummond  coming  out  of  Peel's  house,  he  shot  him  in  the 
back,  believing  him  to  be  Peel,  and  without  any  known  or 
apparent  provocation.  There  was  evidence  also  that  the 
deed  was  premeditated.  It  is  interesting  to  observe  the 
advanced  view^s  of  that  day  entertained  by  Mr.  Cockburn, 
the  counsel  for  the  defence.  In  addressing  the  jury,  he  said 
that  this  must  be  regarded  not  as  a  case  of  complete  insanity, 
but  of  partial  insanit}',  '  what  a  great  French  authority  had 
denominated  homicidal  monomania.'  The  term  '  homicidal 
monomania  '  was,  however,  unfortunate,  because  it  conveys 
no  idea  of  visible,  palpable  mental  derangement,  merely  a 
mania  to  kill,  which  judges  are  naturally  suspicious  of  as 
exonerating  crime. 

There  was  ample  evidence  to  justif}'  this  view  of  the  case 


LEGAL  AND  CIVIL  ASPECTS  OF  MENTAL  DISEASE     441 

in  the  delusions  of  persecution  which  he  manifested.  He 
beHeved  he  was  followed  by  spies.  He  went  to  England  to 
avoid  them,  then  to  France  ;  but  they  were  there  before 
him.  In  other  respects  he  seemed  as  rational  as  men  in 
general. 

The  case  was  tried  by  three  judges,  including  the  Lord 
Chief  Justice,  who  submitted  the  following  test  question  to 
the  jury  :  Had  the  prisoner  that  competent  use  of  his  under- 
standing as  to  know  that  the  act  was  a  wicked  and  a  wrong 
thing,  contrary  to  the  laws  of  God  and  man  ?  McNaughton 
was  acquitted,  confined  as  a  lunatic,  and  showed  afterwards 
unmistakable  evidence  of  mental  disease. 

The  point  of  importance  here  is  the  one  test  by  which 
this  case  was  decided — the  test  of  right  and  wrong,  or  to 
interpret  this  in  legal  phraseology  as  Lord  Brougham  did, 
'  The  right  is  when  you  act  according  to  law,  and  the  wrong 
is  when  you  break  it.'  This  test  is  not  always  so  rigidly 
employed  now ;  for  some  men  know  right  and  wrong  who 
are  insane,  as  in  the  case  of  an  undoubtedly  insane  man 
who  murdered  his  wife,  and  said  that  he  knew  he  would  be 
hung  for  it.     He  was  acquitted  on  the  ground  of  insanity. 

Mr.  Justice  Stephen,  a  judge  of  great  authority  in  such 
matters,  in  the  course  of  his  charge  to  the  jur}-  at  a  trial  in 
1888,  gave  his  views  on  the  subject  thus :  '  It  is  said  that, 
according  to  the  law,  a  man  is  responsible  for  his  acts  when 
he  knows  that  the  act  is  wrong,  and  that  is  true.  Now, 
medical  men  frequently  say  that  many  persons  who  are 
really  mad  do  know  that  the  act  is  wrong.  Now,  if  you 
will  exercise  your  judgment  in  the  matter,  you  will  probably 
see  that  knowing  the  act  is  wrong  means  nothing  more  or 
less  than  the  power  of  thinking  about  it,  the  same  as  a  sane 
man  would  think  about  it  ;  the  power  of  attaining  to  a  full 
conception  of  the  horrible  guilt  there  would  be  in  murder  ; 
the  power  of  knowing  that  you  are  doing  that  which  will 
destroy  life  and  your  soul,  and  cause  sorrow  and  terror,  and 
every  kind  of  frightful  consequence  ;  the  power  of  thinking 
about  all  this — that  power  which  every  sane  man  possesses. 
That  is  the  law,  as  I  understand  it,  which  by  guilt  implies 
the  power  of  discriminating  between  right  and  wrong  ;   that 


442  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

is  the  test  of  responsibility'   (Tuke's   'Dictionary/,'  copied 
from  Western  Mail,  March  15,  1888). 

This  is  a  fine  piece  of  forensic  argument,  but  it  is  specious 
pleading  after  all.  Did  the  man  who  murdered  his  wife, 
knowing  it  to  be  wrong  in  the  e3'e  of  the  law,  possess  the 
power  of  thinking  about  it  the  same  as  a  sane  man  would, 
the  power  of  attaining  to  a  full  conception  of  the  horrible 
guilt  there  would  be  in  murder,  or  did  he  realize  the  full 
enormity  and  after-consequences,  beyond  the  fact  that  he 
would  be  hung  ?  Assuredly  not.  Even  when  men  do  know 
right  from  wrong,  in  the  legal  sense  of  a  breaking  of  the 
law,  their  moral  consciousness  may  be  great  or  small. 

Instances  occur  of  men  who  illustrate  to  the  full  the 
description  given  by  Mr.  Justice  Stephen,  men  of  keen 
moral  consciousness,  men  impelled  to  crime,  and  terrified 
at  the  very  thought  of  it.  Such  cases  are  known  in  the 
experience  of  those  who  have  had  much  experience  of  mental 
disease.  One  gentleman,  perfectly  rational  in  all  respects, 
sought  asylum  protection  because  of  the  obsession  that  he 
must  commit  murder  whenever  he  saw  a  knife. 

Macdonald's  '  Criminal  Law  of  Scotland  '  treats  of  this 
question  in  these  words  :  '  Insanity  or  idiocy  exempts  from 
prosecution.  But  there  must  be  an  alienation  of  reason  such 
as  misleads  the  judgment,  so  that  the  person  does  not  know 
"  the  nature  of  the  quality  of  the  act "  he  is  doing,  or  if  he 
does  know  it,  that  he  does  not  know  he  is  doing  what  is 
wrong.  If  there  be  this  alienation,  as  connected  with  the 
act  committed,  he  is  not  liable  to  punishment,  though  his 
conduct  may  be  otherwise  rational.  For  example,  if  he  kill 
another  when  under  an  insane  delusion  as  to  the  conduct 
and  character  of  the  person,  e.g.,  believing  that  he  is  about 
to  murder  him,  or  is  an  evil  spirit — -then  it  matters  not  that 
he  has  a  general  notion  of  right  and  wrong.  For  in  such  a 
case  "as  well  might  he  be  utterly  ignorant  of  the  quality  of 
murder."  He  does  the  deed,  knowing  murder  to  be  wrong, 
but  his  delusion  makes  him  believe  he  is  acting  in  self- 
defence  or  against  a  spirit.  Nor  does  it  alter  the  effect  of 
the  fact  of  insanity  that  the  person  after  recovers.' 

In  giving  evidence  in  such  cases,  it  must  be  clearly  borne 


LEGAL  AND  CIVIL  ASPECTS  OF  MENTAL  DISEASE    443 

in  mind  that  speculation  and  abstract  statements  are  more 
likely  to  prejudice  the  case  than  otherwise.  If  there  are 
delusions,  probe  them  thoroughly,  and  look  out  for  a  con- 
nection between  them  and  overt  acts.  The  evidence  that 
appeals  to  the  legal  mind  and  to  a  jury  is  that  which  can  be 
talked  about  as  real  and  tangible — evidence  that  can  be 
drawn  from  the  patient,  if  necessary,  at  any  time.  It  is  true 
that  such  cogent  evidence  is  not  obtainable  in  all  cases,  and 
then  the  man's  whole  history,  family  and  personal,  must  be 
looked  into,  and  the  question  asked.  Is  this  crime  consistent 
with  his  past  life  ?  Despite  the  severe  tests  already  laid 
down,  merciful  verdicts  are  given,  where  everything  has  been 
taken  into  account,  and  mental  cases  of  this  kind  deserve  the 
most  careful  examination. 

If  a  medical  man,  owing  to  the  chance  that  a  crime  has 
been  perpetrated  in  his  neighbourhood,  is  called  in,  and 
requires  to  give  evidence  as  to  the  mental  condition  of  the 
culprit,  he  should  be  particular  (i)  to  take  notes  while  his 
observations  are  fresh  ;  (2)  to  quote  the  man's  words — these 
represent  facts,  not  theories  ;  (3)  to  judge  of  his  conscious- 
ness of  his  position  ;  and  his  memory  of  what  has  occurred  ; 
to  elicit  (4),  if  possible,  his  explanation,  if  any;  (5)  to  find 
out  if  he  has  delusions  or  hallucinations. 

When  this  is  done,  it  is  wase  to  repeat  the  examination  a 
day  later,  and  collect  all  the  evidence  that  can  be  obtained 
from  other  sources  bearing  on  the  case,  so  that  whether  pro 
or  con  the  evidence  in  toto  may  decide  whether  sane  or 
insane.  It  is  convenient  here  to  insert  the  remark  that  a 
lunatic's  evidence  against  another  may  be  taken  in  a  court 
of  law  if  any  medical  man  can  certify  that  he  is  mentally 
competent  to  give  such  evidence.  In  cases  of  partial  insanity 
this  can  be  done  sometimes,  also  in  cases  of  melancholia,  in 
particular  circumstances.  On  the  evidence  of  a  lunatic  an 
attendant  has  been  sentenced  for  cruelty  to  a  patient. 

Interference  with  a  Man's  Action  or  Liberty. 

It  is  here  that  medical  men  are  most  frequently  called 
upon  to  exercise  special  legal  and  civil  functions.  To  inter- 
fere with  a  man's  actions  is,  of  course,  to  interfere  with  his 


444  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

liberty  in  a  modified  sense  ;  but  when  interference  with 
liberty  is  spoken  of  here,  we  mean  restraint  on  personal 
freedom,  so  that  a  man  is  confined,  and  cannot  order  his 
outgoings  and  incomings  as  he  pleases. 

Short  of  being  agents  in  securing  this,  medical  men  find 
an  exercise  for  their  functions  in  (a)  undertaking  and 
arranging  for  private  treatment,  with  more  or  less  restraint 
on  liberty,  for  which  a  legal  process  may  not  be  necessary ; 
{b)  in  certifying  as  to  a  man's  competence  to  manage  his 
business  and  personal  affairs  ;  (c)  in  certifying  as  to  a  man's 
testamentary  capacity.  In  addition  he  may  be  asked  to  give 
a  certificate  of  sanity,  or  to  testify  to  a  lunatic's  competence 
to  give  evidence  in  a  law-court. 

In  dealing  with  all  these  subjects,  it  must  be  remembered 
that  legal  formalities  and  legal  use  and  wont  are  not  the 
same  in  all  countries,  and  that  even  in  different  parts  of  the 
British  Isles  great  diversity  of  practice  and  formality  obtains. 
Much  that  has  to  be  said,  however,  deals  with  general 
principles  applicable  to  all  parts  of  this  country ;  and 
wherever  possible  a  distinction  will  be  drawn  between 
English,  Scotch,  and  Irish  customs. 

Certificates  of  Insanity  for  Asylum  Committal. 

At  the  outset  a  practical  distinction  can  be  drawn  between 
those  who  are  to  be  sent  to  asylums  at  the  instance  of  a 
public  authority  and  paid  for  by  the  rates,  so-called  pauper 
lunatics,  an  unfortunate  and  misleading  term — for  many  are 
not  real  paupers — and  those  to  be  sent  at  the  instance  of  a 
relative  or  friend,  and  paid  for  out  of  a  private  purse,  so- 
called  private  lunatics.  Some  medical  men  decline  to  grant 
certificates  of  lunacy  for  asylum  detention,  because  of  the 
many  vexatious  and  extortionate  actions  that  have  been 
raised  against  members  of  the  profession  in  courts  of  law. 
Such  actions,  however,  are  not  nearly  so  common  as  they 
were  ten  or  fifteen  years  ago,  a  special  enactment  having 
been  passed  securing  all  medical  men  who  shall  act  bond-fide, 
and  with  reasonable  care,  from  such  claims.  This  applies  to 
England  ;  but  in  Scotland  it  is  so  rare  for  such  actions  to  be 
raised  that  this  risk  may  also  be  discounted  there. 


LEGAL  AND  CIVIL  ASPECTS  OF  MENTAL  DISEASE    445 

With  pauper  lunatics  there  is  httle  or  no  risk,  for  obvious 
reasons,  and  even  needy  lawyers  on  the  look-out  for  specula- 
tive cases  find  such  too  speculative  for  their  resources.  The 
insane,  however,  when  they  recover,  may  not  have  entirely 
lost  their  feelings  of  suspicion  and  distrust,  and  some  are 
normally  quarrelsome  and  litigious.  It  is  well,  therefore,  to 
have  a  legal  guarantee  of  immunity  in  doubtful  cases  before 
granting  a  medical  certificate. 

When  a  medical  man  is  called  in  to  give  a  certificate  of 
lunacy,  he  should  keep  four  cardinal  points  in  view  :  First, 
how  best  to  see  the  patient ;  second,  how  best  to  draw  him 
out ;  third,  if  insane,  is  asylum  treatment  necessar}^  ?  fourth, 
if  asylum  treatment  is  necessary,  how  best  to  certify  him. 

In  the  examination  of  a  mental  case,  a  medical  man  must 
take  care  that  he  is  not  put  in  a  false  position  at  the  outset. 
The  friends  are,  it  may  be,  so  afraid  of  the  patient,  and  of 
incurring  his  anger  and  displeasure,  that  they  wish  to  intro- 
duce the  doctor  not  as  a  medical  man  at  all.  Or  doubtful 
that  the  patient  may  put  a  curb  on  his  speech  and  temper  if 
he  knows  who  is  the  interviewer,  they  wish  him  to  give  him- 
self away,  so  to  speak,  before  he  finds  out  the  true  state  of 
affairs. 

Now,  it  is  a  well-known  axiom  of  asylum  practice  that  the 
straightforward,  honest  course  is  best  for  the  patient  in  the 
end  ;  and  if  the  doctor  called  in  happens  to  be  the  family 
doctor,  as  is  frequently  the  case,  there  is  no  reason  why  he 
should  not  see  and  examine  the  patient  without  by  his 
presence  or  his  interrogation  suggesting  asylum  treatment. 
So  long  as  he  does  not  deliberately  mislead  the  patient,  there 
can  be  no  harm  done.  In  any  case,  whether  the  family 
doctor  or  not,  it  should  be  stated  that  the  doctor  has  been 
called  in  on  account  of  the  patient's  health.  There  are 
exceptions  to  this  rule  where  stratagem  must  be  tried,  as 
when  a  man  barricades  his  room  or  his  house  against  all 
comers.  At  the  same  time  let  there  be  no  unnecessary 
evasion. 

Before  seeing  the  patient,  it  is  well  to  be  primed  with  the 
facts  of  the  case  as  they  may  be  learned  from  relatives  or 
others.     We  should  always  be  observant  of  the  friends   as 


446  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

well,  for  one  never  knows  if  a  case  is  bond-fide,  where  all  are 
strangers.  The  friends,  if  the  case  is  bond -fide,  and  it  is 
rare  to  find  it  otherwise,  materially  assist  the  medical  man 
beforehand  in  the  preparation  of  his  case.  From  these  he 
gets '  the  cue,  otherwise  he  might  travel  very  wide  of  the 
mark. 

Having  been  introduced  to  the  patient,  the  next  question 
is  how  best  to  draw  him  out.  The  busy  practitioner  should 
not  be  in  a  hurry — '  more  hurry  less  speed  ' — nor  should  he 
brusquely  plunge  in  medias  res.  He  should  be  wary,  remem- 
bering that  the  patient  is  likely  to  be  suspicious ;  and  he 
should  not  look  like  a  man  with  an  evident  purpose.  In 
society  the  weather  is  the  premier  topic  of  conversation.  In 
the  examination  of  mental  cases  we  must  not  be  artificial, 
but  natural,  catching  our  inspiration  from  the  circumstances 
of  the  moment.  The  golden  rule  is  by  tact  and  patience  to 
gain  the  patient's  favour  and  allay  suspicion.  As  no  two 
cases  are  alike,  specific  rules  cannot  be  laid  down;  but  one 
is  important  as  applied  to  patients  who  talk — do  not  inter- 
rupt ;  guide  them  gently,  imperceptibly,  in  a  desired  channel 
if  you  please,  but  do  not  abruptly  interpose  in  their  garrulous 
flow. 

The  third  question  is,  If  the  patient  is  insane,  is  asylum 
treatment  necessary?  The  first  point,  then,  for  us  is,  to 
settle  in  our  own  minds  the  question.  Is  the  man  insane  ? 
This  will  be  discussed  under  the  next  head ;  but  assuming 
that  he  is  insane,  is  asylum  treatment  necessary?  I  have 
referred  to  the  circumstances  in  which  the  medical  man  is 
here  placed  in  the  chapter  on  '  Treatment,'  and  the  matter 
will  here  be  disposed  of  in  a  few  words.  If  the  patient  is  in 
a  position  to  justify  it,  if  the  mental  attack  can  be  treated  in 
a  private  house  without  injury,  mentally  or  physically,  to 
himself  or  others,  and  if  the  friends  are  agreeable,  then 
asylum  treatment  is  not  necessary.  If  the  patient  is  poor, 
his  case  a  curable  one  and  urgent,  or  too  severe  for  unskilled 
treatment  at  home,  the  case  is  one  for  an  asylum  at  the 
earliest  possible  moment.  If  the  patient  is  poor,  his  case 
incurable,  his  condition  such  as  can  be  treated  in  a  private 
dwelling,  requiring  kindly  care  rather  than  skilled  treatment, 


LEGAL  AND  CIVIL  ASPECTS  OF  MENTAL  DISEASE    447. 

he  may  be  provided  for  in  a  private  dwelling,  if  such  is 
obtainable.  The  law  as  applied  to  single  patients  being 
treated  at  home  or  boarded  out  will  be  afterwards  re- 
ferred to. 

The  fourth  question,  how  best  to  certify  a  patient,  must 
be  looked  at  from  two  points  of  view — the  matter  and  the 
manner  of  the  certificate.  The  matter  of  the  certificate,  the 
data  of  the  man's  lunacy,  is  of  course  all-important ;  but  the 
data  may  be  all  that  one  could  wish  for  in  a  strong  certificate, 
and  yet  the  certificate  prove  invalid  because  of  the  manner 
in  which  it  is  filled  up.  A  medical  man  cannot  be  too  par- 
ticular in  filling  up  a  lunacy  certificate,  and  he  should  read 
the  side-notes  and  foot-notes,  if  any,  carefully  beforehand, 
and  before  he  finally  lets  the  paper  pass  from  his  hands. 
The  fact  that  a  certificate  is  carefully,  fully,  and  accurately 
filled  up  will  of  itself  go  far  to  establish  the  bond  fide  of  the 
man  who  grants  it. 

The  matter  of  the  certificate,  the  data  on  which  a  diagnosis 
of  insanity  is  founded,  must  be  expressed  in  intelligible 
English,  and  must  conclusively  prove  to  the  justice,  judge, 
or  sheriff,  that  the  man  is  insane.  Unfortunately,  warrants 
are  granted  from  time  to  time  on  slender  grounds,  and  in  a 
very  perfunctory  manner ;  but  one  never  knows  when  they 
may  be  pulled  up  sharp,  and  the  Commissioners— especially 
in  England,  where  they  are  particular  almost  to  the  dotting 
of  an  i — may  send  back  certificates  for  correction. 

The  matter  of  the  certificate  is  included  under  two  heads  : 
(a)  facts  indicating  insanity  observed  by  the  medical  man 
himself,  he  having  visited  and  examined  the  patient  sepa- 
rately from  any  other  medical  man;  (b)  facts  indicating 
insanity  communicated  by  others.  The  first  series  of  facts 
must  be  the  kernel  of  the  certificate,  and  in  arranging  them 
and  putting  them  on  paper  some  skill  and  circumspection  is 
required.  In  some  instances  the  facts  are  few  and  weak,: 
and  they  must  be  made  the  most  of  consistent  with  accuracy; 
but  in  these  cases  it  is  often  possible  to  strengthen  an  other-, 
wise  weak  certificate  with  stronger  '  facts  communicated  by 
others.'  Some  very  absurd  statements  are  sometimes  put 
under  the  first  head.     The  following  may  serve  as  warning 


448  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

examples  of  '  facts  indicating  insanity '  observed  by  medical 
men  : 

'  He  says  he  is  a  teetotaler,  and  never  tasted  drink  in  his 
life.' 

'  He  says  he  was  converted  six  years  ago,  but  has  back- 
slidden.' 

'  He  says  he  would  be  quite  content  if  he  had  a  cup  of 
tea.' 

'  He  says  that  he  is  not  married  that  he  is  aware  of.' 

'  When  I  examined  the  patient,  I  could  detect  nothing 
that  would  justify  his  being  confined  in  an  asylum  ;  but  the 
facts  communicated  to  me  by  the  attendant  are  sufficient  to 
show  that  he  is  a  person  that  ought  to  be  confined  in  an 
asylum.' 

I  well  remember  the  stereotyped  '  facts  '  that  used  to  be 
recorded  by  a  country  doctor  of  the  old  school,  whether  the 
case  was  mania,  melancholia,  or  stupor.  The  one  description 
did  for  all :  '  Wild,  staring,  bloodshot  eyes,  foaming  at  the 
mouth.' 

To  state  that  the  patient  is  excited,  restless,  incoherent, 
is  to  give  facts  of  a  certain  value  in  themselves,  but  not 
sufficient  to  justify  the  granting  of  a  warrant.  To  say  that 
the  patient  has  a  sad,  sullen,  or  irritable  expression,  that  he 
will  not  speak  or  do  anything  for  himself,  are  also  in  the 
same  category.  With  such  small  shot,  however,  if  in  suffi- 
cient amount,  a  medical  certificate  may  be  charged  to  as 
good  purpose  as  if  it  stated  delusions  or  hallucinations. 

There  is  no  doubt,  however,  that  the  justice  or  judge  can 
appreciate  more  clearly  such  statements  as  the  following  : 
(i)  This  man  has  delusions  of  unseen  agency ;  he  says  that 
men  are  working  on  him  with  poison  and  electricity.  He 
has  the  delusion  that  men  control  his  speech  and  his  thoughts, 
and  he  has  hallucinations  of  hearing,  such  as  that  he  hears 
men  saying  they  will  pump  dirt  into  him.  (2)  Says  he  is 
a  captain,  which  is  a  delusion.  Says  he  is  the  Duke  of 
Scotland.  Note,  it  is  not  necessary  here  to  add  '  which  is  a 
delusion,'  for  the  delusion  is  sufficiently  obvious. 

It. is  a  good  plan,  when  the  facts  are  strong,  to  give  the 
patient's    own    words,    and    in    repeating   what    he    says,   if 


LEGAL  AND  CIVIL  ASPECTS  OF  MENTAL  DISEASE    449 

a  delusion  is  contained  in  the  statement,  add,  '  which  is  a 
delusion,'  unless  the  statement  is  so  absurd  and  extravagant 
or  insane  as  to  speak  for  itself. 

Under  the  second  head,  facts  communicated  by  others,  is 
included  the  information  which  may  have  been  obtained 
prior  to  seeing  the  patient.  These  facts  may  be  stronger 
than  the  preceding ;  but  in  any  case  they  are  contributory 
in  greater  or  less  degree  according  to  the  skill  with  which 
they  are  worked  into  the  certificate.  It  is  of  great  import- 
ance to  give  correctly  the  name  and  designation  of  the 
person  or  persons  giving  such  information — not  to  say  his 
mother,  sister,  brother,  a  neighbour,  or  an  attendant.  The 
man's  name  may  be  John  Smith,  and  the  mother's  name  by 
a  second  marriage  Mrs.  Webster.  He  may  have  many 
sisters  or  brothers,  neighbours  innumerable,  and  the  identity 
of  the  attendant  might  not  be  an  easy  matter  afterwards. 

The  manner  of  the  certificate  is  important.  It  must  be 
remembered  that  it^is  a  legal  document,  a  potent  weapon 
against  a  man's  liberty,  and.  it  should  be  regarded  as  neces- 
sitating care  in  its  composition.  In  the  first  place,  the 
certificate  must  clearly  and  unmistakably  identify  the  man 
who  grants  it,  and  the  man  against  whom  it  is  granted.  It 
won't  do  for  the  doctor  to  give  an  insufficient  name  and 
address,  or  to  state  that  he  has  examined  Brown,  Jones,  or 
Robinson,  without  saying  which  of  them,  where  he  resides, 
and  what  his  designation  is.  In  the  case  of  a  pauper  patient, 
it  must  be  added  after  the  designation,  '  a  pauper.' 

Several  other  points  might  here  be  referred  to.  They  are 
the  small  shot  in  the  form  of  the  certificate,  and  must  not 
be  disregarded.  A  careful  study  of  the  side-notes  will  keep 
the  certifier  correct,  and  with  these  side-notes  to  guide  him 
there  is  no  excuse  for  a  certificate  faulty  in  form.  It  should 
be  carefully  read  over  before  being  signed. 

Treatment  in  a  private  house  is  restricted  and  supervised 
in  England  and  Scotland.  In  England  the  law  as  to  single 
-patients  is  very  strict,  and  prosecutions  at  the  instance  of 
■the  Commissioners  in  Lunacy  are  frequently  instituted 
against  those  who  take  private  patients  for  payment  without 
ja.'UcQnse.to  do   so.  ,  In  Scotland  a,  little  more  latitude  is 

29 


450  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

allowed,  although  when  once  a  case  is  officially  recognised 
it  is  well  looked  after.  The  Scotch  law  is  in  effect  very 
much  the  same  as  the  more  recent  English  law  on  the 
subject  (Sec.  XIII.  and  XIV.  of  Act  29  and  30  Vict., 
Cap.  51— Scotland). 

Section  XIII. — Section  XLI.  of  the  first-recited  Act  is  hereby  re- 
pealed ;  and  in  lieu  thereof,  no  person  shall  receive  or  keep  any  person  as 
a  lunatic  for  gain  without  the  order  of  the  Sheriff  or  the  sanction  of  the 
Board  ;  and  any  person  who  shall  receive  into  or  keep  in  his  house  any 
such  person,  or  any  person  alleged  to  be  a  lunatic,  shall,  within  fourteen 
clear  days  thereafter,  make  application  for  such  order  or  sanction,  pro- 
vided always  that,  when  the  lunatic  is  a  pauper  lunatic,  such  application 
shall  be  made  by  the  Inspector  of  the  Poor,  and  it  shall  be  lawful  in  such 
case  for  the  Sheriff  to  grant  his  order  on  one  medical  certificate.  And 
every  such  lunatic  shall  be  visited,  as  often  as  the  Board  shall  regulate, 
by  a  medical  person,  who  shall  enter  in  a  book  to  be  kept  in  such  house 
the  date  of  each  visit,  and  the  condition  of  the  mental  and  bodily  health 
of  the  lunatic  at  each  such  visit ;  and  any  medical  person  who  shall  make 
any  such  entry  without  having  visited  the  patient  within  seven  days  of 
making  such  entry,  or  who  shall  knowingly  make  any  false  entry  in  such 
book,  shall  be  liable  in  a  penalty  not  exceeding  ^10  for  each  offence. 
And  it  shall  be  in  the  power  of  the  Board  to  order  such  inspection  and 
visitation  of  every  such  house  from  time  to  time  as  to  them  shall  seem 
proper.  And  every  person  detaining  or  aiding  in  detaining  any  such 
lunatic,  or  any  person  who  on  inquiry  is  found  to  be  a  lunatic,  without 
the  order  of  the  Sheriff  or  the  sanction  of  the  Board,  or  after  such  order 
or  sanction  has  been  withdrawn,  shall  be  liable  in  a  penalty  not  exceeding 
^20  ;  provided  that  the  enactments  of  this  section  shall  not  apply  to  any 
case  where  the  Person  so  received  and  kept  has  been  sent  to  such  house 
for  the  purpose  of  temporary  residence  only,  not  exceeding  six  months, 
and  under  the  certificate  of  a  Medical  Person,  which  certificate  shall  be 
in  the  form  of  Schedule  G  to  the  first-recited  Act  annexed. 

Section  XIV. — Section  XLIII.  of  the  first-recited  Act  is  hereby  re- 
pealed ;  and  in  lieu  thereof,  if  any  occupier  or  inmate  of  any  private  house 
shall  keep  or  detain  therein,  without  the  order  of  the  Sheriff  or  the 
sanction  of  the  Board,  any  person  as  a  lunatic,  although  not  for  gain, 
beyond  the  period  of  one  year,  and  the  malady  is  such  as  to  require 
compulsory  confinement  to  the  house,  or  restraint  or  coercion  of  any 
kind,  such  occupier  or  inmate  shall  intimate  the  case  to  the  Board,  and 
shall  state  the  reasons  which  render  it  desirable  that  such  lunatic  should 
remain  under  private  care  ;  and  if  the  Board  shall  have  reason  to  believe 
or  suspect  that  any  lunatic,  or  any  person  treated  as  a  lunatic,  whose 
case  has  thus  been  intimated  to  them,  or  of  whose  case  no  such  intima- 
tion shall  have  been  made,  has  been  subjected  to  compulsory  confinement 
to  the  house,  or  to  restraint  or  coercion  of  any  kind,  at  any  Jime  beyond 


LEGAL  AND  CIVIL  ASPECTS  OF  MENTAL  DISEASE    451 

a  year  after  the  commencement  of  the  malady,  or  has  been  subjected  to 
harsh  and  cruel  treatment,  it  shall  be  lawful  for  the  Board,  with  consent 
of  one  of  Her  Majesty's  principal  Secretaries  of  State,  or  of  Her 
Majesty's  Advocate  for  Scotland,  to  authorize  and  empower  any  one  or 
more  of  the  members  thereof  to  visit  and  inspect  such  lunatic  or  person 
detained  as  a  lunatic,  and  to  make  such  inquiry  respecting  his  treatment, 
as  to  such  member  or  members  may  seem  fit  ;  and  if  on  such  inquiry  it 
shall  appear  that  such  person  is  a  lunatic,  and  has  been  so  for  a  space 
exceeding  a  year,  and  that  compulsory  confinement  to  the  house,  or 
restraint  or  coercion  of  any  kind,  has  been  resorted  to,  or  that  he  has 
been  subjected  to  harsh  and  cruel  treatment,  and  that  the  circumstances 
are  such  as  to  render  the  removal  of  such  lunatic  to  an  asylum  necessary 
or  expedient,  it  shall  be  lawful  for  the  Board  to  apply  to  the  Sheriff  under 
a  procedure  similar  to  that  followed  in  the  cases  of  dangerous  lunatics, 
and  the  Sheriff,  on  being  satisfied  that  the  person  is  lunatic,  and  has 
been  so  for  more  than  a  year,  and  is  subjected  to  compulsory  confine- 
ment, or  to  restraint  or  coercion  of  any  kind,  or  to  harsh  and  cruel 
treatment,  shall  issue  his  order  for  the  transmission  of  the  lunatic  to  an 
asylum,  and  his  detention  therein  until  such  time  as  the  Board  shall 
sanction  his  discharge.  And  the  Sheriff"  shall  grant  decree  for  the 
expenses  of  the  inquiry  and  procedure,  and  also  for  the  maintenance  of 
the  lunatic  in  the  asylum,  against  the  parties  legally  liable  for  the  main- 
tenance of  such  lunatic. 

In  England  the  care  and  treatment  of  patients  outside  of 
asylums  is  determined  by  the  following  section  (315)  of  the 
Lunacy  Act,  i8go :  (i)  '  Every  person  who,  except  under 
the  provisions  of  this  Act  .  .  .  for  payment  takes  charge  of, 
receives  to  board  or  lodge,  or  detains,  a  lunatic  or  alleged 
lunatic  in  an  unlicensed  house,  shall  be  guilty  of  a  mis- 
demeanour, and  shall  also  be  liable  to  a  penalty  not  exceeding 
£S^.  .  .  .  Except  under  the  provisions  of  this  Act,  it  shall 
not  be  lawful  for  any  person  to  receive  or  detain  two  or 
more  lunatics  in  any  house,  unless  the  house  is  an  institu- 
tion for  lunatics  or  a  workhouse,  .  .  .  Any  person  who 
receives  or  detains  two  or  more  lunatics  in  any  house, 
except  as  aforesaid,  shall  be  guilty  of  a  misdemeanour.' 
The  Commissioners  have,  however,  the  power  to  sanction 
the  reception  in  an  unlicensed  house  of  more  than  one  single 
patient  (Section  XLVI.).  It  is  necessary,  therefore,  for  those 
taking  responsible  charge  of  a  patient  for  gain  in  a  private 
house  to  see  that  the  patient  has  been  duly  certified,  and 
that  a  judicial  order  has  been  obtained  for  his  detention^ 
'  29 — 2 


452  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

A  medical  man  cannot  certify  and  take  charge  of  the  same 
patient.  It  is  competent  for  him  to  do  the  one  or  the  other 
only.  The  forms  and  authority  for  the  reception  of  such  a 
case  vary  according  as  (i)  the  lunatic  has  been  '  so  found  by 
inquisition  ' — in  other  words,  a  Chancery  patient ;  (2)  the 
order  is  a  judicial  reception  order;  (3)  or  an  urgency  order, 
which  is  valid  for  seven  days  from  date  thereof,  and  is 
intended  to  secure  and  protect  the  patient  while  a  judicial 
reception  order  is  being  obtained.  Ample  instruction  is 
given  to  medical  men  in  Mercier's  small  monograph  '  Lunacy 
Law  for  Medical  Men,'  and  those  who  practise  in  England, 
and  have  to  do  with  cases  treated  singly,  or  borderland  cases, 
would  do  well  to  consult  it,  as  it  contains  much  useful 
information. 

Certificates  of  Sanity. 

These  may  be  required  to  set  aside  any  disability  which 
has  been  raised  by  a  certificate  of  lunacy,  mental  or  busi- 
ness incompetence,  and  they  are  the  most  difficult  to  grant, 
and  require  the  exercise  of  much  caution  and  common-sense 
in  considering  the  question  at  all.  It  is  a  much  easier  thing 
to  certify  a  man  insane  than  to  prove  that  he  is  sane.  Men 
reputedly  sane  are  discharged  from  asylums  every  day, 
because  they  have  restrained  their  speech  and  otherwise 
exercised  self-control.  In  cases  of  alleged  illegal  detention 
in  asylums,  the  friends  of  a  patient,  or  the  Commissioners, 
may  require  ah  independent  medical  examination  of  the 
patient,  with  a  view  to  ascertaining  whether  he  is  insane 
or  no.  The  presumption  will  be  that,  if  the  medical  officers 
of  the  asylum  are  acting  bond-fide,  they  know  best,  and  while 
a  medical  man  from  the  outside  may,  in  rare  instances,  be 
able  to  brush  some  cobwebs  from  the  asylum  medical  officer's 
view  of  the  case,  it  will  be  well  to  consult  with  the  asylum 
physician  and  give  a  report  rather  than  a  certificate.  It  is, 
however,  necessary  from  time  to  time  to  grant  such  a  certifi- 
cate, and  all  that  requires  to  be  said  is  that  great  caution 
should  be  exercised. 

Law  of  Interference  with  a  Lunatic's  Property. 

■  The  mere  placing  a  man  in  an  asylum  does  not  give  the^ 
right  to  anyone  to  interfere  with  his   property  or  effects, 


LEGAL  AND  CIVIL  ASPECTS  OF  MENTAL  DISEASE    453 

which  are  practically  locked  up  until  he  recovers,  or  until  a 
responsible  factor  is  appointed  to  deal  with  them.  This  latter 
implies  expense,  greater  in  England  and  Ireland,  where  the 
mode  of  procedure  is  more  formal  and  cumbrous,  than  in 
Scotland.  In  order  to  obviate  this,  attempts  may  be  made 
to  get  the  lunatic  to  sign  cheques,  receipts,  etc. ;  but  this  is 
an  evasion  of  the  law,  and  no  matter  how  extenuating  the 
circumstances  of  the  case,  such  action  should  receive  no 
countenance  from  medical  men. 

The  simplest  procedure  is  the  Scotch,  which  is  known  as 
the  appointment  of  curator  bonis  ;  and  the  expense,  which 
should  not  exceed  ;^i5,  is  so  small  as  to  obviate  any  necessity 
for  evading  the  law.  A  petition  for  the  appointment  of  a 
curator  bonis,  with  a  statement  of  the  lunatic's  affairs,  may 
be  made  by  a  near  relative,  or,  in  the  case  of  there  being  no 
relative,  anyone  interested  in  the  case,  an  inspector  of  poor 
or  other  official  where  the  patient  is  nominally  a  pauper,  or 
even  the  lunatic  himself,  but  I  have  never  known  this  done. 
Until  1880  application  had  to  be  made  to  the  Court  of 
Session.  Since  then,  however,  the  procedure  is  much  less 
expensive,  as  the  petition  and  medical  certificates  can  be 
presented  in  any  Sheriff  Court.  The  medical  certificates  may 
be  drawn  up  in  this  form  : 

'  I,  A.  B.,  being  a  registered  medical  practitioner  and  a 
graduate  in  medicine  of  the.  University  of  Edinburgh  [or  a 
licentiate  of  the  Royal  College  of  Physicians,  Edinburgh], 
do  certify,  on   soul  and  conscience,  that  I   have  this  day  at 

C (full  address),  in  the  County  of  D ,  visited  and 

separately  examined  E.  F.  ;  that  I  am  of  opinion  that  he  is 
a  lunatic  (or  an  idiot,  or  a  person  of  unsound  mind),  and 
unable  to  manage  his  affairs,  or  to  give  directions  for  their 

management.     Dated   at   ,  this  fifteenth   day  of  April, 

eighteen  hundred  and  ninety-seven. 

(Signed)  A.  B.' 

In  some  cases  a  statement  of  the  probable  duration  of  the 
incapacity  may  be  required,  but  I  have  never  known  of  this 
being  done. 

In  England  the  Court  of  Chancery  may,  in  the  case  of 
certain  insane  persons  with  limited  means,  direct  that  these 


454  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

be  devoted  to  their  benefit.  This  is  rare  ;  the  almost  invariable 
rule  is  to  have  a  formal  inquiry  before  a  lunacy  commission. 
A  petition  is  presented  to  the  Lord  Chancellor  by  a  relative 
of  the  lunatic,  supported  by  affidavits,  medical  and  non- 
medical, the  former  dealing  with  his  mental  condition,  the 
latter  with  his  property.  The  medical  affidavits  should  be 
full  and  ample,  giving  particulars  of  the  mental  state, 
describing  its  character,  and  making  clear  the  fact  of  the 
man's  mental  unsoundness.  After  this  an  inquiry  is  held 
by  a  Master  in  Lunacy,  who  goes  and  sees  the  individual 
concerned,  inquires  fully  into  the  mental  condition  and 
regarding  the  property  of  the  lunatic,  and  gives  orders 
how  he  is  to  be  disposed  of,  and  at  what  expense.  In  the 
case  of  dependent  relatives,  he  also  determines  what  allow- 
ances shall  be  disbursed  to  them  from  the  estate. 

In  Ireland  the  custom  is  very  much  on  the  lines  of  the 
English  practice  just  described  ;  but  the  Lord  Chancellor, 
where  the  estate  is  not  worth  more  than  -^2,000,  or  the 
income  not  more  than  ;£'ioo,  may  apply  it  for  the  lunatic's 
benefit  without  inquisition.  In  Ireland,  moreover,  the  case 
may  go  to  a  jury  in  a  common  law  court.  The  Lord  Chan- 
cellor has  considerable  latitude  in  dealing  with  Chancery 
cases. 

Certificates  of  Testamentary  Capacity. 

An  insane  person  may  make  a  valid  will ;  but  unless 
certificates  of  testamentary  capacity  have  been  obtained  at 
the  time  when  the  will  was  signed,  the  presumption  follows 
that  the  will  is  invalid.  Men  and  women  may  scheme  to  get 
wills  drawn  up  so  as  to  obtain  certain  legacies,  and  others 
may  scheme  to  upset  them.  The  testator  may  be  drugged  or 
intoxicated  so  as  to  become  more  pliable  in  the  hands  of 
the  plotters.  Such  being  sometimes  the  case,  suspicion 
may  be  roused,  especially  if  the  testator  has  been  an  old 
person,  and  the  will  may  be  declared  invalid  in  a  court  of 
law.  Those  interested  in  the  provisions  of  the  will  are 
naturally  anxious  that  nothing  will  be  done  to  upset  these 
provisions  afterwards.  Family  quarrels  often  lead  to  later 
disputes  in  this  respect ;  and  the  precaution  is  now  frequently 


LEGAL  AND  CIVIL  ASPECTS  OF  MENTAL  DISEASE    455 

taken  to  have  certificates  of  testamentary  capacity,  one  from 
the  family  doctor,  and  the  other  from  a  mental  physician. 
This  ought  to  be  understood,  that  there  need  be  no  hesita- 
tation  merely  because  the  testator  is  insane  ;  for  even  insane 
persons  may  be  able  not  only  to  make  a  good  will,  but  to 
manage  property,  and  give  directions  for  the  management  of 
their  affairs.  It  requires  less  mental  capacity  to  make  a 
valid  will  than  to  manage  property. 

The  examination  of  a  would-be  testator  should  be  con- 
ducted alone  if  possible  ;  and  if  not  possible,  owing  to  the 
patient's  health  or  for  other  reason,  the  person  in  attendance 
should  be  one  not  interested  in  the  will.  At  such  a  time  the 
relatives  or  others  in  attendance  must  be  regarded  as  people 
who  ma}^  consider  that  they  have  claims  on  the  testator, 
and  their  influence  must  be  entirely  cut  off  for  the  time 
being.  Bearing  this  in  mind,  the  patient  should  be  carefully 
examined,  to  ascertain  with  certainty  whether  he  is  in  an 
artificial  mental  state  due  to  alcohol  or  other  inebriant.  Mere 
excitement  is,  of  course,  no  justification  for  this  conclusion. 

It  is  well  when  there  is  excitement,  and  in  old  people  this 
is  more  often  noticeable,  to  wait  patiently,  and  not  touch  on 
the  special  object  of  the  visit  at  first,  for  the  patient  must 
show  at  his  best  as  regards  memory  and  judgment.  When 
the  subject  is  broached,  it  may  be  discussed  in  general  terms, 
and  the  family  history  may  be  discussed  in  order  to  learn 
whether  undercurrents  are  at  work  and  where,  and  in  order 
to  estimate  the  emotional  character  of  the  testator.  He 
may  show  passion  or  prejudice  against  members  of  his 
family  ;  but  it  may  within  certain  free  limits  be  quite  con- 
sistent with  a  valid  will. 

The  important  question  is,  to  be  satisfied  that  he  clearly 
realizes  what  he  commits  himself  to,  knows  in  particular 
terms  (not  necessarily  to  be  expressed  in  figures)  what  the 
contents  of  the  property  are,  how  it  is  to  be  disposed  of, 
and  to  whom.  Another  point  of  importance  is  to  test  the 
memory,  and  here  is  the  opportunity ;  but  it  is  well  to  test 
it  more  than  once,  later  the  same  day,  or  on  the  following 
morning.  In  the  examination  of  such  a  case,  the  questions 
and  answers  should  be  written   down,  and  the  same  ques- 


456  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

tions  repeated  at  the  next  visit,  the  answers  being  compared. 
The  certificate,  for  which  there  is  no  prescribed  form,  should 
be  given  on  soul  and  conscience,  and  ought  to  be  accurate  as 
to  time  and  place,  name,  and  the  designation  of  the  testator. 
The  following  is  the  will  of  a  phthisical  patient  suffering 
from  mania  with  religious  exaltation  : 

'  Hartwood, 

Glasgow, 

March  i()th,  1897. 
I  the  under  sined 

Mrs.  B 

do  Bequath  first  to  Dr.  Beddell  my  scotish  hymnal 

Lady  ferguson  the  Butifully  Pictuir  of  Jesus  sitting  wearied 
and  wating  at  the  Jacobs  Well 

Lady  Ballantine  my  Cruch  Bible 

Miss  Denholm  Religous  Storray  Book 

Mrs.  Lady  Riddle  My  Butiefull  Callander  with  the  green 
Cross  on  it  and  the  ladj-es  fase  that  is  on  it  very  much 
resembles  her  own  a  butfull  face 

My  Dauter  and  Suninlaw  all  the  Rest  Between  my  two 
kind  sisters 

Not  forgetting  all  the  Poor  Patients  hear  May  god  land 
them  all  in  heaven 

May  god  send  gernal  Booths  army  hear  soon 

Mrs.  B 

Mrs.  G 

Mrs.  C ' 

Many  confidential  duties  are  required  of  medical  men  with 
respect  to  mental  disease.  Here  medical  reticence,  loyalty 
to  the  patient  and  his  friends,  is  a  first  duty.  Questions 
affecting  the  future  of  the  young  may  give  rise  to  family 
disclosures,  implying  a  confidence  which  must  be  held  sacred. 
In  advising  as  to  the  future  one  must  be  careful.  No  man 
even  with  the  key  of  science  can  unlock  the  door  which  hides 
the  future,  and  the  evolution  of  many  of  our  least  promising 
patients  may  be  more  gratifying  than  we  have  dared  to 
expect.  On  the  subject  of  marriage  and  the  possibility  of 
the  propagation  of  nervous  or  mental  disease,  I  know  of  no 


LEGAL  AND  CIVIL  ASPECTS  OF  MENTAL  DISEASE    457 

more  thankless  task  than  giving  advice.  The  man  or  woman 
who  inherits  potential  insanity  is  just  that  person  who  is 
most  eager  for  marriage,  and  will  not  be  governed  in  the 
choice  of  a  partner.  They  are  those  of  all  others  to  whom 
it  is  no  use  to  preach  celibacy.  Medical  men  will  be  con- 
sulted on  this  subject  from  time  to  time.  In  some  cases 
their  advice  will  be  taken,  but  as  a  rule  it  will  not.  . 

LUNACY   FORMALITIES    IN    USE   IN    ENGLAND, 
WITH  INSTRUCTIONS. 

TO  PLACE  AN  INSANE  PERSON  UNDER  CONTROL. 

Private  Patient. 

If  a  person,  not  a  pauper,  becomes  insane  whilst  staying 
with  his  or  her  family  or  friends,  who  are  prepared  to  take 
steps  to  place  him  or  her  under  control,  it  may  be  done  in 
one  of  three  ways  : 

1.  By  a  judicial  order  on  petition. 

2.  By  an  urgency  order. 

3.  By  an  inquisition  in  lunacy. 

The  first  method  is  the  one  usually  adopted. 

When  this — the  judicial  order  on  petition — method  is 
adopted,  a  petition,  accompanied  by  a  statement  of  particulars, 
and  by  two  medical  certificates,  is  presented  to  a  judicial 
authority,  who  may  then,  if  he  sees  fit,  give  the  reception 
order. 

The  petition  should,  if  possible,  be  presented  by  the 
husband,  wife,  or  other  relative  of  the  patient.  When,  how- 
ever, it  is  presented  by  some  other  person  not  a  relative,  the 
document  must  set  forth  why  husband,  wife,  or  other  relative 
did  not  sign  it,  also  the  connection  of  the  petitioner  with 
the  patient,  and  the  circumstances  under  which  he  presents 
the  petition. 

The  judicial  authority  may  be  '  the  County  Court  Judge,' 
'the  stipendiary  magistrate,'  or  a  'justice  of  the  peace.' 
Not  every  justice  of  the  peace,  however,  is  competent  to 
make  the  reception  order.  Before  he  can  take  the  position 
of  a  'judicial  authority'  in  these  cases,  he  must  be  specially 


438  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

appointed  by  his  brother  justices.  When  a  justice  is  so 
appointed,  he  can  act  in  any  district  without  any  considera- 
tion as  to  whether  the  district  comes  under  his  ordinary 
jurisdiction  or  not. 

A  provisional  order  may  be  made  by  any  justice,  and  be- 
comes permanent,  if  approved  and  signed  by  a  'judicial 
authority '  within  fourteen  days  after  its  date. 

The  name  and  address  of  the  nearest  justice  of  the  peace, 
specially  appointed  under  this  Act,  may  be  learnt  from  the 
magistrates'  clerk,  whose  address  may  be  learnt  at  the 
nearest  police-station. 

It  will  be  noted  that  the  petition  is  never  filled  up  by  a 
medical  man,  as  a  medical  man,  nor  can  he  sign  either  of  the 
certificates  if  a  relative  or  connection  of  his  signs  the 
petition. 

A  statement  of  particulars  must  always  accompany  the 
petition.     The  following  is  the  form  used  : 

STATEMENT  OF  PARTICULARS. 

Statement  of  particulars  referred  to  in  the  annexed  Petition  [or  in  the 
above  or  annexed  Order'] . 

The  following-  is  a  statement  of  particulars  relating  to  the  said 

Name    of    Patient,    with    Christian  \ 
Names  at  length        -         -         -\ 

Sex  and  Age    ----- 

Married,  Single,  or  Widowed  - 

Rank,  Profession,  or  previous  Occu- ) 
pation  (if  any)    -         -         -  -  ) 

Religious  Persuasion 

Residence  at  or  immediately  previous  ] 
to  the  date  hereof      -         -         -\ 

Whether  first  Attack         -         .        - 

Age  on  first  Attack  -         -         -      .  - 

When  and  where  previously  under 
Care  and  Treatment  as  a  Lunatic, 
Idiot,  or  Person  of  Unsound 
Mind  ----- 

Duration  of  existing  Attack 
Supposed  Cause       .         -         .         . 


LUNACY  FORMS  IN  USE  IN  ENGLAND  459 


Whether  subject  to  Epilepsy    - 

Whether  Suicidal      -         -         -         - 

Whether  Dangerous  to  others,  and  in  | 
what  Way ) 

Whether  any  near  Relative  has  been  } 
afflicted  with  Insanity        -         -  j 

Name,  Christian  Names,  and  full 
Postal  Addresses  of  one  or  more 
Relatives  of  the  Patient     - 

Name  of  Person  to  whom  notice  of ', 
Death  to  be  sent,  and  full  ' 
Postal  Address,  if  not  already  ( 
given  -         -         -         -         -  y 

Name  and  full  Postal  Address  of  the  1 
usual  Medical  Attendant  of  the  > 
Patient ) 


{Signed}^ 


When  the  petitioner  or  person  signing  an  urgency  order  is  not  the 
person  who  signs  the  statement,  the  following  particulars  must  be  added 
about  him  or  her  : 

Name,  with  Christian  Names  at  length. 

Rank,  Profession  or  Occupation  (if  any). 

How  related  to  or  otherwise  connected  with  the  Patient. 


THE  MEDICAL  CERTIFICATES. 

Signing  certificates  of  lunacy,  as  I  have  already  observed, 
was  formerly  a  matter  of  serious  risk  to  the  medical  man  ; 
but  since  the  passing  of  the  Act  of  i8go  the  risk  of  subse- 
quent legal  proceeding,  against  him  is  greatly  diminished, 
and  may  be  almost  entirely  obviated  if  he  has  acted  in  good 
faith  and  with  reasonable  care,  as  may  be  seen  from  the 
following  statutory  extract  (Lunacy  Act,  i8go)  : 

'  If  any  proceedings  are  taken  against  any  person  for  sign- 
ing or  carrying  out  or  doing  any  act  with  a  view  to  sign  or 
carry  out  any  such  order,  report,  or  certificate,  or  presenting 
any  petition  as  in  the  preceding  subsection  mentioned,  or 
doing  anything  in  pursuance  of  this  Act,  such  proceedings 
may,  upon  summary  application  to  the  High  Court,  or  a 
Judge  thereof,  be  stayed  upon  such  terms  as  to  costs  and 
otherwise  as  the  Court  or  Judge  may  think  fit,  if  the  Court 


46o  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

or  Judge  is  satisfied  that  there  is  no  reasonable  ground  for 
alleging  want  of  good  faith  or  reasonable  care.' 

It  will  be  seen  from  this,  that  it  is  always  necessary  to  be 
very  cautious  in  signing  certificates,  and  also  that,  when 
proper  caution  is  taken,  there  can  be  very  little  risk  of 
recrimination — hurtful  recrimination — on  the  patient's  part. 

Medical  practitioners  must  endeavour  in  their  certificates 
of  insanity  to  make  the  evidence  as  clear  as  possible,  bear- 
ing constantly  in  mind  that  the  document  is  to  be  scrutinized 
by  lawyers. 

The  petition  must  be  accompanied  by  two  medical  certifi- 
cates, each  on  a  separate  sheet  of  paper. 

If  possible,  one  of  the  certificates  must  be  written  by  the 
usual  medical  attendant  of  the  patient,  but  when  not  possible, 
the  reason  why  must  be  stated  in  writing  to  the  judical 
authority  to  whom  the  petition  is  presented. 

In  certain  cases  a  practitioner  is  debarred  from  signing  a 
certificate,  but  the  only  case  which  may  be  mentioned  here 
is  when  the  practitioner  is  related  in  some  way  to  the  patient 
or  petitioner. 

The  examination  on  which  the  certificate  is  based  must  be 
made  within  a  period  of  seven  clear  days  before  the  presenta- 
tion of  the  petition.  N.B. — It  is  the  examination,  not  the 
date  of  signature  of  the  certificate,  which  must  be  not  more 
than  seven  days  apart  from  the  presentation. 

Nothing  will  be  said  here  about  filling  up  the  part  of  the 
certificate  following  '  facts  indicating  insanity,'  as  what  has 
already  been  written  on  the  subject  must  suffice.  Even  to 
give  a  short  summary  of  what  might  be  considered  '  facts 
indicating  insanity  '  would  take  up  unnecessary  space,  seeing 
that  the  subject  has  already  been  dealt  with  in  a  different 
relation.  It  is  enough,  therefore,  to  say  here  that  the  facts 
must  be  cogent,  concisely  stated,  and  intelligibly  set  forth. 

The  forms  of  medical  certificate  in  use  in  Scotland  here- 
after appended  will  serve  as  a  guide  for  England  also, 
although  in  the  two  countries  they  are  somewhat  different. 


LUNACY  FORMS  IN  USE  IN  SCOTLAND  461 


LUNACY  FORMS  IN  USE  IN  SCOTLAND. 


25  &  26  Vict.,  Cap.  54,  Sect.  14. 

PETITION  TO  THE  SHERIFF  TO   GRANT  ORDER  FOR 

THE  RECEPTION  OF  A  PATIENT  INTO  AN 

ASYLUM. 

Unfo  the  Ho7iourabIe  the  (i)  of  the  {^') 

of  and  his  Substitutes, — 

The  Petition  of 
humbly   sheweth   that   it   appears    from   the   subjoined    Statement    and 
accompanying  Medical  Certificates,  that 
your  Petitioner's  (^) 

is  at  present  in  a  state  of  Mental  Derangement,  and  a  proper  person  for 
treatment  in  an  Asylum  for  the  Insane.  May  it  therefore  please  your 
Lordship  to  authorize  the  transmission  of  the  said 

to  the  and  to  sanction  admission 

into  the  said  Asylum. 

{To  be  signed  by  the  Party  applying) 

Dated  this  (*)  day  of  One  thousand  eight 

hundred  and 

STATEMENT. 

If  any  of  the  particulars  in  this  Statement  be  not  known,  the  fact  to  he 

so  stated. 

1.  Christian  Name  and  Surname  of 

Patient  at  length    - 

2.  Sex  and  Age       .         .         -         - 

3.  Married,  Single,  or  Widowed     -  . 

4.  Condition  of  Life,  and  previous  \ 

Occupation  (if  any)         -         -  \ 

5.  Religious   Persuasion,  so  far  as  \ 

known    -         -         -         -         - | 

^  Sheriff  or  Steward.  ^  Shire  or  Stewartry. 

^  State  degree  of  Relationship  or  other  capacity  in  which  Petitioner  stands  to 
Lunatic. 

■*  The  date  of  the  Petition  must  be  within  fourteen  clear  days  following  the  dates 
of  the  Medical  Certificates. 


462  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

6.  Previous  Place  of  Abode    - 

7.  Place  where  Found  and  Examined 

8.  Length  of  time  Insane 

9.  Whether  first  Attack  - 

10.  Age  (if  known)  on  first  Attack  - 

11.  When     and     where     previously^ 

under  Examination  and  Treat-  r 
ment  (°) J 

12.  Duration  of  existing  Attack 

13.  Supposed  Cause 

14.  Whether  subject  to  Epilepsy 

15.  Whether  Suicidal 

16.  Whether  Dangerous  to  others    - 

17.  Parish  or   Union  to  which   the  ^ 

Lunatic     (if    a     Pauper)     is  r 
Chargeable    -         -         -         -  J 

18.  Christian    Name   and    Surname  \ 

and     Place     of     Abode  of 

nearest    known     Relative  of 

the    Patient,    and    degree  of 
Relationship  (if  known),  and 

whether     any     Member  of 

Family   known   to    be    or  to 
have  been  Insane  - 

19.  Special    circumstances   (if  any)  "] 

preventing  the  insertion  of  any  r 
of  the  above  particulars  -         -  J 

I  certify  that,  to  the  best  of  my  knowledge,  the  above  particulars  are 
correctly  stated. 

Dated  this  day  of  One  thousand  eight 

hundred  and 

{To  be  signed  by  the  Party  applying) 


5  If  Patient  has  been  previously  in  an  Establishment,  state  fact,  and  date  of  latest 
admission  or  approximation  thereto.  If  never  previously  under  examination  or 
treatment,  state  fact. 


LUNACY  FORMS  IN  USE  IN  SCOTLAND  463 


MEDICAL  CERTIFICATE,  No.    i. 

1 ,  the  undersigned 

being  a  (^) 

and  being  in  actual  practice  as  a  (-) 

do  hereby  certify,  on  soul  and  conscience,  that  I  have  this  day,  at (3) 

in  the  County  of 
separately  from  any  other  Medical  Practitioner, 
visited  and  personally  examined  ("*) 

and  that 
the  said  is  a  (^) 

and  a  proper  person  to  be  detained 
under  Care  and  Treatment,  and  that  I  have  formed  this  opinion  upon  the 
following  grounds,  viz. : — ■ 

1.  Facts  indicating  Insanity  observed  by  myself:  C') 

2.  Other  facts  (if  any)  indicating  Insanity  communicated  to  me  by 


others 


Name  and  Medical  \ 
Designation        ) 

Place  of  Abode 


Dated  this  day  of  One  thousand  eight 

hundred  and 

^  Set  forth  the  qualification  entitling  the  Person  certifying  to  grant  the  Certificate 
e.g..  Member  of  the  Royal  College  of  Physicians  in  Edinburgh. 
^  Physician  or  Surgeon,  or  otherwise,  as  the  case  may  be. 

^  Insert  the  Street  and  Number  of  the  House  (if  any),  or  other  like  particulars. 
^  Insert  Designation  and  Residence,  and  if  a  Pauper,  state  so. 
^  Lunatic,  or  an  Insane  Person,  or  an  Idiot,  or  a  Person  of  Unsound  Mind. 
8  State  the  facts. 
^  State  the  Information,  and  from  whom  derived. 


464  CLINICAL  MANUAL  OF  MENTAL  DISEASES 


MEDICAL  CERTIFICATE,  No.   2. 

1 ,  the  undersigned, 

being  a^-) 

and  being  in  actual  practice  as  a  (-) 

do  hereby  certify,  on  soul  and  conscience,  that  I  have  this  day,  at(^) 

in  the  County  of 
separately  from  any  other  Medical  Practitioner, 
visited  and  personally  examined  ("') 

and  that 
the  said  is  a  (^) 

and  a  proper  person  to  be  detained 
under  Care  and  Treatment,  and  that  I  have  formed  this  opinion  upon  th6 
following  grounds,  viz.  : — 

1.  Facts  indicating  Insanity  observed  by  myself  :  {'') 

2.  Other  facts  (if  any)  indicating   Insanity  communicated  to  me  by 

others  :  (") 


Name  and  Medical  \ 
Desigjiation        j 


■  Tlace'  of  Abode  _ 


Dated  this  day  of  One  thousand  eight 

hundred  and 

^  Set  forth  the  qualification  entitling  the  Person  certifying  to  grant  the  Certificate, 
e.g..  Member  of  the  Royal  College  of  Physicians  in  Edinburgh. 
-  Physician  or  Surgeon,  or  otherwise,  as  the  case  may  be. 

■*  Insert  the  Street  and  Number  of  the  House  (if  any),  or  other  like  particulars. 
■*  Insert  Designation  and  Residence,  and  if  a  Pauper,  state  so. 
^  Lunatic,  or  an  Insane  Person,  or  an  Idiot,  or  a  Person  of  Unsound  Mind. 
^  State  the  facts, 
^  State  the  Information,  and'from  whom  derived. 


LUNACY  FORMS  IN  USE  IN  SCOTLAND  465 


CERTIFICATE  OF  EMERGENCY. 

( T/a's  Certificate  authorizes  the  detention  of  a  Patient  in  an  Asylum  for  a 
period  not  exceeding  three  days  without  any  Order  by  the  Sheriff^ 

1  ,  the  undersigned, 

being  (i) 

hereby  certify,  on  soul  and  conscience,  that  I  have  this  day,  at(^) 
in  the  County  of  ,  seen  and  personally  examined 

,  and  that  the  said 
person  is  of  unsound  mind,  is  a  proper  Patient  to  be  placed  in  an  Asylum, 
and  is  in  a  sufficiently  good  state  of  bodily  health  at  this  date  to  be 
removed  to  the  Asylum  at  (^) 

And   I  further   certify  that   the   case   of  the  said   person   is   one  of 
Emergency. 


Dated  this  day  of  One  thousand  eight 

hundred  and 


{The  following  should  be  filled  up  in  every  case  in  which  a  Certificate  of 
Emergency  is  acted  on.) 


I 


hereby  request  the  Superintendent  of  the 


Asylum  to  receive  therein 
■  to  whom  the  foregoing  Certificate  of  Emergency  refers. 

Relationship  or  other 
capacity  in  which 
Applicant  stands 
to  Patient 


Signature  and  Address 
Date 


^  State  Medical  Qualification. 
"^  State  Place  of  Examination. 
^  State  Place  at  which  Asylum  is  situated. 


30 


466  CLINICAL  MANUAL  OF  MENTAL  DISEASES 


ORDER  TO  BE  GRANTED  BY  THE  SHERIFF  FOR  THE 

TRANSMISSION  AND  RECEPTION  OF  THE 

LUNATIC. 

I,  (')      - 

of  the  (2)  of 

having  had  produced  to  me,  with  a  Petition  at  the  instance  of  (^) 

Certificates  under  the  hands  of 

and  ,  being  two  Medical  Persons 

duly  qualified  in  terms  of  an  Act  intituled  '  An  Act  for  the  Regulation  of 
the  Care  and  Treatment  of  Lunatics,  and  for  the  Provision,  Maintenance, 
and  Regulation  of  Lunatic  Asylums  in  Scotland,'  setting  forth  that  they 
had  separately  visited  and  examined  {^) 

and  that  the  said 
is  a  (^) 
and  a  proper  Person  to  be  detained  and  taken  care  of,  DO  hereby 
AUTHORIZE  you  to  receive  the  said 

as  a  Patient  into  the  (")  Asylum 

of  and  I  authorize 

Transmission  to  the  said  Asylum  accordingly  ;  and  I  transmit  you  here- 
with the  said  Medical  Certificates,  and  a  Statement  regarding  the  said 

which  accompanied  the 
said  Petition. 

Dated  [at  ]  this  day  of 

One  thousand  eight  hundred  and 

To  the  Superintendent  of  the  (') 
Asylicm  of 

[  Signature^ 


^  State  whether  Sheriff,  Sheriff-Substitute,  Steward,  or  Steward-Substitute. 

-  State  whether  a  County  or  Stewartry. 

"*  Insert  Name  and  Designation. 

■*  Describe  him,  and  if  a  Pauper,  state  so. 

5  Lunatic,  or  an  Insane  Person,  or  an  Idiot,  or  a  Person  of  Unsound  Mind. 

^  Public,  District,  Parochial,  or  Private. 

"  Public,  District,  Parochial,  or  Private. 


LUNACY  FORMS  IN  USE  IN  IRELAND 


467 


LUNACY  FORMS  IN  USE  IN  IRELAND. 


County  of 

to  wit. 


FORM    D. 
FORM  OF  APPLICATION  FOR  ADMISSION. 

The  following  Declaration,  Forms,  and  Certificates  are  to  be  filled 
up,  perfected,  and  transmitted  to  the  Resident  Medical  Superintendent  at 
the  time  of  the  Lunatic  being  sent  to  the  Institution. 

No  application  will  be  attended  to  which  does  not  state  the  Name, 
Residence,  and  Occupation,  and  degree  of  relationship  of  the  two  next 
male  relatives,  and  the  next  female  relative  of  the  patient  (when  such 
exists),  according  to  the  annexed  Form,  when  it  is  possible  to  give  those 
particulars. 

It  is  requested  that  a  person  will  accompany  the  patient  to  the  Asylum, 
who  is  able  to  give  the  best  information  respecting  his  or  her  disease, 
former  mode  of  life,  etc.  ;  and  it  is  expected  that  the  Lunatic  will  be 
properly  clad. 

I.  Declaration. 

1 ,  ,  of  ,  in  the  County  of  (state 
occupation),  do  solemnly  and  sincerely  declare  that 
,  residing  at  ,  in  the  Parish  of 
and  County  or  City  of  ,  is  insane,  and  has  been  so  for  , 
and  that  the  said  is  destitute,  and  has  no  friend  who  is  wiUing  or 
able  to  support  in  a  private  or  other  establishment  for  insane,  and 
that  has  been  a  resident  in  the  County  or  City  of  for  , 
and  that  the  information  in  the  annexed  Forms  is  correct.  And  I  make 
this  solemn  Declaration,  conscientiously  believing  the  same  to  be  true, 
and  by  virtue  of  the  provisions  of  an  Act  made  and  passed  in  the 
Sixth  Year  of  the  Reign  of  His  late  Majesty  King  William  the  Fourth 
(5  &  6  Wm.  IV.,  cap.  62),  intituled  'An  Act  to  repeal  an  Act  of  the 
present  Session  of  Parliament,  intituled  "An  ^ct  for  the  more  effectual 
Abolition  of  Oaths  and  Affirmations,  taken  and  made  in  various  Depart- 
ments of  the  State,  and  to  substitute  Declarations  in  lieu  thereof,  and  for 
the  more  entire  suppression  of  Voluntary  and  extra  judicial  Oaths  and 
Affidavits,  and  to  make  other  provisions  for  the  Abolition  of  unnecessary 
Oaths." '  

Made  and  subscribed  at  in  said  County  of 

,  before  Me,  a  Justice  of  the  Peace  for 
said  County,  this  day  of  ,  18     . 


(Stamp.) 


Forms  referred  to  in  the  foregoing  Declaration  ;    to  be  filled  up  and 
signed  by  the  friends  of  the  Lunatic  : 

Names  of  the*Two  next  Akin  to  the  Lunatic. 


Relatives'  Names. 

Residence. 

Occupation. 

Degree  of  Reladonship. 

i 

30—2 


468  CLINICAL  MANUAL  OF  MENTAL  DISEASES 


I 


,  C D ,  having  read  the  certificate  of  E F ,  of  , 

a   duly  qualified   medical  practitioner,  and  being  satisfied   that  A 

B is  in  such  circumstances  as  to  require  relief  for  his  proper  care  and 

maintenance,  and  that  the  said  A B is  a  lunatic  (or  an  idiot,  or 

person  of  unsound  mind),  and  a  proper  person  to  be  taken  charge  of  and 

detained  under  care  and  treatment,  hereby  recommend  the  said  A 

B for  detention  as  a  patient  in  your  asylum.     Subjoined  is  a  state- 
ment of  particulars  respecting  the  said  A B . 

(Sig7ied)  C D , 

A  Justice  of  the  Peace  for 


STATEMENT  OF  PARTICULARS. 
If  any  particulars  are  7iot  known,  the  fact  is  to  be  so  stated. 

The  following  is  a  Statement  of  Particulars  relating  to  the  said 
Name    of    Patient,    with    Christian 

Name  at  length     -         -         -         - 
Sex  and  Age     ----- 

Married.  Single,  or  Widowed  - 
Rank,  Profession,  or  previous  Occu-  ) 

pation  (if  any)       -         -         -         -S 
Religious  Persuasion         .         .         - 
Residence  at  or  immediately  previous  \ 

to  the  date  hereof-         -         -         -  )' 
Whether  first  Attack 
Age  on  first  Attack  -         -         -         . 
When  and   where  previously  under 

Care  and  Treatment  as  a  Lunatic, 

Idiot,  or  Person  of  Unsound  Mind 
Duration  of  existing  Attack 
Supposed  Cause        -         -         .         - 
Whether  subject  to  Epilepsy    - 
Whether  Suicidal     -         .         -         - 
Whether  Dangerous  to  others,  and 

in  what  way  ----- 
Whether  any  near  Relative  has  been  / 

afflicted  with  Insanity   -         -         -  ) 
Union  to  which  Lunatic  is  Charge-  ( 

able -  « 

Names,   Christian  Names,   and   full  ^ 

Postal  Addresses  of  one  or  more  \ 

Relatives  of  the  Patient  -         -J 

Name  of  the  Person  to  whom  Notice  \ 

of  Death  to  be  sent,  and  full  Postal  ) 

Address,  if  not  already  given         -) 

( Signed) 


Dated  the  day  of 


LUNACY  FORMS  IN  USE  IN  IRELAND  469 


CERTIFICATE  OF  MEDICAL  PRACTITIONER. 

In  the  matter  of  ,  of  (^)  ,  in  the  County  of  (^) 

(^)  ,  an  alleged  Lunatic.     I,  the  undersigned  ,  do  hereby 

certify  as  follows  : 

r.  I  am  a  person  registered  under  the  Medical  Act,  1858,  and  I  am  in 
the  actual  practice  of  the  Medical  Profession. 

2.  On  the  day  of  ,189  ,  at  (*)  ,  in  the  County 
of  (•5)  ,  I  personally  examined  the  said  ,  and  came  to  the 
conclusion  that  he  is  (^)  ,  and  a  proper  Person  to  be  taken 
charge  of  and  detained  under  care  and  treatment. 

3.  I  formed  this  conclusion  on  the  following  grounds,  viz.  : 

(a)  Facts  indicating  Insanity  observed  by  myself  at  the  time  of 

Examination  {^),  viz.  : 
(d)  Facts  communicated  by  others  (^),  viz.  : 

4.  The  said  appeared  to  me  to  be  in  a  fit  condition  of  bodily 
health  to  be  removed  to  an  Asylum  (^). 

Dated  this  day  of  One  thousand  eight 

hundred  and  ninety 

{Signed) ,  of  (^O)  

^  Insert  residence  of  patient. 

-  County,  city,  or  borough,  as  the  case  tnay  be. 

■^  Insert  profession  or  occupation  (if  any). 

*  Insert  the  place  of  examination,  giving  the  name  of  the  street,  with  number 
or  name  of  house,  or  should  there  be  no  number,  the  Christian  and  surname  of 
occupier. 

^  County,  city,  or  borough,  as  the  case  may  be. 

°  A  lunatic,  an  idiot,  or  a  person  of  unsound  mind. 

'  If  the  same  or  other  facts  were  observed  previous  to  the  time  of  the  examina- 
tion, the  certifier  is  at  liberty  to  subjoin  them  in  a  separate  paragraph. 

^  The  names  and  Christian  names  (if  known)  of  informants  to  be  given,  with 
their  addresses  and  descriptions. 

*  Strike  out  this  clause  in  case  of  a  patient  whose  removal  is  not  proposed. 
^^  Insert  full  postal  address. 


Through  the  kindness  of  Dr.  Oscar  Woods  I  have  been 
enabled  to  give  the  foregoing  forms ;  but  Dr.  Woods  writes 
to  me  that,  although  these  should  be  looked  on  as  the 
ordinary  forms  of  admission,  they  are  not  made  use  of  so 
frequently  as  might  be  expected  '  on  account  of  the  over- 
crowding of  Irish  asylums,  and  for  other  reasons,  chiefly 
perhaps  from  the  fact  that  no,  official  is  made  responsible 
for  the  correct  filling  up  of  these  forms.'  The  patient  is 
instead  made  nominally  a  criminal,  and  committed  on  the 
following  form  : 


470  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

COMMITTAL   WARRANT   OF   A    DANGEROUS  LUNATIC 
OR  A  DANGEROUS  IDIOT, 

To  be  signed  by  Two  Magistrates  sitting  together. 


1)1  pursiia7ice  of  Act  30  and  31   Vict.^  c.  118. 


County  of  \  By  Two  or  more  Justices  of  the  Peace  in 

to  wit.  S  and  for  said  County. 

To  the  Resident  Medical  Superintendent  of  the  Asylum  at 

Whereas,  by  Informations  sworn  before  us  by  (})  of  (^) 

on  the  (3)                 day  of  18 

it  has  been  proved  to  our  satisfaction  that  ("*)  of  (■^) 

by  occupation  a  (**) 
has  been  discovered  and  apprehended  at  (")  under  circum- 
stances denoting  a  derangement  of  mind,  and  a  purpose  of  committing  an 
indictable  crime,  that  is  to  say  (*) 

And  whereas  we  have  called  to  our  assistance  (^)  of  C) 

who  is  (") 

And  whereas  the  said  (^^)  has  duly  examined 

the  said  (■*)  and  has  duly  certified  by  the 

Medical  Certificate  annexed  hereto  that  the  said 
is  now  a  dangerous  ('*') 
And  whereas  we  have  seen  and  examined  the  said  (*) 

and  upon  the  evidence  aforesaid  and  our  view  and  examina- 
tion aforesaid  are  satisfied  that  the  said  (*)  is 
now  a  dangerous  (^'') 

We  therefore  direct  that  the  said  (*)  shall 

forthwith  be  taken  to  the  said  District  Lunatic  Asylum  at  (f^) 
which  is  the  Lunatic  Asylum  for  the  said  County  (^^)  in 

which  County  (i*)  the  said  (•*)  vi'as 

discovered  and  apprehended  as  aforesaid. 

And  we  hereby,  in  Her  Majesty's  name,  charge  and  command  you, 
the  aforesaid  Resident  Medical  Superintendent  of  the  said  Asylum,  to  re- 
ceive and  detain  in  the  said  Asylum  the  body  of  the  said  (*) 

and  there  safely  to  keep  until  removed  therefrom,  or 
otherwise  discharged  by  due  course  of  law,  and  for  your  so  doing  this 
shall  be  your  sufficient  Warrant  and  Authority. 

Given  under  our  Hands  and  Seals,  at  this 

day  of  18 

J.P.  Seal. 

J.P.  Seal. 

The  attention  of  the  Magistrates  is  particularly  requested  to  the  pro- 
ceedings required  under  the  provisions  of  the  loth  clause  of  the  Act  30 
and  31  Vict.,  c.  118. 


LUNACY  FORMS  IN  USE  IN  IRELAND  471 


^  ^  ^  Here  state  Name  and  Address  of  each  Informant,  and  date  of  each  Infor- 
mation. 

*  Here  state  Name  of  Lunatic  or  Idiot. 

•'  Here  state  Place  of  Abode  of  Lunatic  or  Idiot. 

^  Here  state  Position  in  Life  of  Lunatic  or  Idiot. 

''  Here  state  Name  of  Place  and  County,  County  of  a  City,  County  of  a  Town, 
City,  or  Town,  as  case  may  be,  in  which  discovery  and  apprehension  took  place. 

^  Here  state  the  facts  from  which  it  appears  that  the  person  was  discovered  and 
apprehended  under  circumstances  denoting  a  derangement  of  mind,  etc. 

"  Here  state  Name  of  Medical  Officer. 

^^  Here  state  Address  of  Medical  Officer. 

^^  If  the  Medical  officer  whom  the  Justices  call  to  their  assistance  is  the  only 
Medical  Officer  of  the  Dispensary  District  in  which  the  Justices  shall  be  at  the 
time,  then  fill  the  blank  left  at  ^^  as  follows  in  Italics,  and  insert  at  ^^  the  name  of 
such  Dispensary  District,  and  at  ^^  the  County,  County  of  a  City,  County  of  a 
Town,  City,  or  Town  in  which  such  Dispensary  District  is  situate,  namely,  '  Tke 
Medical  Officer  of  the  ^-      .       Dispensaty  Distj-ict  situate  in  ^^  and  being  the 

Dispensary  District  in  which  we  now  are. ' 

If  there  is  more  than  one  Medical  Officer  of  the  Dispensary  District  in  which 
the  Justices  shall  be  at  the  time,  the  nearest  available  Medical  Officer  of  such  Dis- 
trict is  to  be  called  by  the  Justices  to  their  assistance,  and  in  that  event  the  blank 
left  at  ^^  is  to  be  filled  as  follows  in  italics — inserting  at-^^  the  name  of  such  Dispensary 
District,  and  at  ^^  the  County,  County  of  a  City,  County  of  a  Town,  City,  or  Town 
in  which  such  Dispensary  District  is  situate,  namely  :  '  The  7iearest  available 
Medical  Officer  of  the  ^-  Dispensary  District  situate  in  ^"^  ,  and  being  the 

Dispensary  District  in  which  we  now  are.' 

If  there  is  no  Medical  Officer  or  no  available  Medical  Officer  of  the  Dispensary 
District  in  which  the  Justices  shall  be  at  the  time,  the  nearest  available  Medical 
Officer  of  any  neighbouring  Dispensary  District  is  to  be  called  by  the  Justices  to 
their  assistance  ;  and  in  that  event  the  blank  left  at  ^^  is  to  be  filled  up  as  follows 
in  italics — inserting  at  ^^  the  name  of  the  Dispensary  District  of  such  Medical  Officer, 
and  at  ^^  the  County,  County  of  a  City,  County  of  a  Town,  City,  or  Town  in  which 
such  Medical  Officer's  Dispensary  District  is  situate,  and  at  ^*  the  name  of  the  Dis- 
pensary District  in  which  the  Justices  shall  be  at  the  time,  and  at  ^'^  the  County, 
County  of  a  City,  County  of  a  Town,  City,  or  Town  in  which  the  Dispensary  Dis- 
trict in  which  the  Justices  shall  be  at  the  time  is  situate,  namely  :  '  The  nearest 
available  Medical  Officer  of  the  ^'^  Dispensaiy  District,  situate  hi  ^^  , 

being  a  neighbouring  Dispensary  District  to  the  i"*  Dispejisary  District,  situate  in  ■'■' 
,  and  in  which  last-mentioned  Dispensary  District  zue  now  are.' 

^*'  '  Lunatic  '  or  '  Idiot,'  as  case  may  be. 

^"^  Here  insert  name  of  Asylum. 

^^  Or  '  County  of  the  City,'  or  '  County  of  the  Town,'  as  case  may  be. 


47: 


CLINICAL  MANUAL  OF  MENTAL  DISEASES 


The  following   Forms  must  be  filled  up  by  the  Medical 
Officer  who  has  personally  examined  the  Lunatic  or  Idiot : 


I 


I.  MEDICAL  CERTIFICATE. 


certify  that 


whom  I  visited  on  day 

of  ,  and  into  whose  case  I  specially  and  personally  in- 

quired, is  now  a  dangerous  0)  ;    and  I  am  of  opinion,  from 

the  nature  of  h     malady,  that     he  is  a  fit  subject  for  speedy  admission 
into  Lunatic  Asylum,  under  the  provisions  of  the  Act  30 

and  31  Vict,  c.  118,  s.  10. 

Date 1 8 

Signature  of  Medical  Officer, 

Residence '. 


Dispensary  District 


2. 

STATEMENT  OF  PARTICULARS  OF  CASE. 

Species  of 
Insanity. 

ProbableCause 
of  Derange- 
ment. 

Prominent 
Symptoms. 

Whether 
affected  with 
BodilyDisease. 

Whether 
Idiotic  or 
Epileptic. 

Facts   indicating 
that  the  Patient 
is  a  Dangerous  (2) 

I  hereby  certify  that  this  Form  is  filled  up  correctly,  to  the  best  of  my 
opinion  and  belief. 

Date  ■ 1 8 

Signature  of  Medical  Officer 


The  following  Forms  must  be  filled  up  by  the  friends  of 
the  Lunatic  or  Idiot. 

If  no  friends  of  the  Lunatic  or  Idiot  are  known,  this 
Form  may  be  filled  up  by  the  Police,  so  far  as  their  informa- 
tion will  enable  them  to  do  so. 

NAMES  OF  THE  TWO  NEXT  AKIN  TO  THE  LUNATIC 
OR  IDIOT. 


Relatives'  Names.           Residence  and  Post  Town^ 

Occupation. 

Degree  of  Relationship. 

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^  '  Here  state  Lunatic  or  Idiot,  as  the  case  may  be. 


LUNACY  FORMS  IN  USE 

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Date 


Signature 


The  asylums  are  maintained  out  of  a  county  rate,  not  a 
poor  rate,  and  relieving  officers  are  therefore  not  responsible 
as  in  England  and  Scotland. 

There  are  no  special  establishments  for  idiots.  Many  are 
in  the  workhouses. 


FORM  OF  UNDERTAKING  FOR  THE  REMOVAL  OF  A 
PATIENT  TO  BE  SIGNED  BY  THE  FRIENDS  OF  THE 
PATIENT,  OR  THE  MAGISTRATE,  CLERGYMAN,  OR 
OTHER  RESPONSIBLE  PERSON  WHO  SIGNS  THE 
APPLICATION  FOR  ADMISSION. 


To  the  Board  of  Governors  of 


District  Lunatic  Asylum. 


Gentlemen, 

In  consideration  of  your  receiving  into  and  maintaining  in  the 
above  Asylum  as  a  Patient,  I  hereby  undertake  that  within 

one  week  from  my  receiving  notification  from  the  Inspectors  of  Lunatic 
Asylums  or  the  Board  of  Governors,  that  the  said  is  no  longer 

a  fit  person  to  be  accommodated  therein,  I  shall  remove  the  said 
from  the  Asylum,  and  in  the  event  of  my  failing  so  to  do,  I  hereby  agree 
to  be  responsible  to  the  Board  for  any  expense  they  may  incur  in  having 

the  said  removed  therefrom,  and  also  for  all  the  costs  of  ■, 

maintenance  in  the  Asylum  after  the  expiration  of  said  week,  and  until 

he 

V     shall  have  been  finally  removed  therefrom. 

Signature ■ 

Dated  this  day  of  ,  i8 


474  CLINICAL  MANUAL  OF  MENTAL  DISEASES 


FORM  E. 

FORM    OF    APPLICATION     FOR     THE     ADMISSION     OF     A 
PAYING  PATIENT  INTO  THE  DISTRICT  LUNATIC 

ASYLUM. 

Declaration. 

County  of  )  A  >  '  residing  at  ,  in  ,  do 

,        .-  I  solemnly  and   sincerely  declare  that  ,  of 

J  ,   in  the   County  of  ,  has,  for 

some  time  past,  been  in  a  state  of  Insanity  and  Mental  Derangement ; 
and  that  the  said  is  unable  to  pay  for  care  and  main- 

tenance, and  has  no  friend  who  will  support  the  said  in  a 

Private  Lunatic  Establishment,  and  that  has  been  a  resident  of 

the  said  County  of  for  the  last  years  ;  and  that  the 

annexed   Certificates   and   Forms   are,   to   the   best   of  my   knowledge, 
correctly  filled  up. 

And  I  make  this  solemn  declaration,  conscientiously  believing  the 
same  to  be  true,  and  by  virtue  of  the  provisions  of  an  Act  made  and 
passed  in  the  Sixth  Year  of  the  Reign  of  His  late  Majesty  King  William 
the  Fourth  (5  &  6  Wm.  IV.,  cap.  62),  intituled  'An  Act  to  repeal  an  Act 
of  the  present  Session  of  Parliament,  intituled  "An  Act  for  the  more 
effectual  Abolition  of  Oaths  and  Affirmations,  taken  and  made  in  various 
Departments  of  the  State,  and  to  substitute  Declarations  in  lieu  thereof, 
and  for  the  more  entire  suppression  of  Voluntary  and  extra  Judicial 
Oaths  and  Affidavits,  and  to  make  other  provisions  for  the  Abolition  of 
unnecessary  Oaths." ' 

Declared  to  by  me, 


Made  and  subscribed  at                ,  in  said  County 
(Stamp.)                   of               ,  before  me,  a  Justice  of  the  Peace 
for  said  County,  this             day  of  ,  18     . 
. — ^ ,  Justice. 


LUNACY  FORMS  IN  USE  IN  IRELAND  475 


STATEMENT. 

If  any  of  the  Particulars  in  this  Statement  be  not  known,  the  fact  to  be  so 

stated. 

•Name  of  Patient,  with  Christian 
Name  at  length     -        -        -        - 

Sex  and  Age    ----- 

Married,  Single,  or  Widowed  - 

Condition  of  Life,  and  previous  Oc- 
cupation (if  any)    -         -         -         - 

Religious  Persuasion,  as  far  as  known 

Previous  Place  of  Abode  -        -        - 

Whether  first  Attack 

Age  (if  known)  on  first  Attack  - 

When  and  where  previously  under 
Care  and  Treatment 

Duration  of  existing  Attack 

Supposed  Cause        ...        - 

Whether  subject  to  Epilepsy    - 

Whether  Suicidal      -         .         -         - 

Whether  Dangerous  to  others  - 

Whether  found  Lunatic  by  Inquisi- 
tion, and  Date  of  Commission  or 
Order  for  Inquisition     - 

Special  .circumstances  (if  any)  pre- 
venting the  Patient  being  examined 
before  Admission  separately  by  two 
Medical  Practitioners    - 

Name  and  Address  of  Relation  to 
whom  Notice    of   Death   may  be 


sent 


{Signed) - 


Where  the  person  signing  the  Statement  is  not  the  person  who  signs 
the  Application,  the  following  particulars  concerning  the  person  signing 
the  Statement  are  to  be  added,  viz.  : 
Occupation  (if  any)  -         -         -         - 
Place  of  Abode         -        -        .         - 

Degree  of  Relationship  (if  any)  or 
other  circumstances  of  connection 
with  the  Patient    -         - 


476  CLINICAL  MANUAL  OF  MENTAL  DISEASES 

FIRST  MEDICAL  CERTIFICATE. 

i ,  the  undersigned,  being  a  (i)  ,  and  being  in  actual  practice 

as  a  (^)  ,  hereby  certify  that  I,  on  the  day  of 

at  (^)  in  the  County  of  ,  (*)  separately  from  any 

other   Medical  Practitioner,   personally   examined   (^)  , 

of  ,  and  that  the  said  is  a  (^)  ,  and  a  proper 

Person  to  be  taken  charge  of  and  detained  under  care  and  treatment,  and 
that  I  have  formed  this  opinion  upon  the  following  grounds,  viz.  : 

1.  Facts  indicating  Insanity  observed  by  myself  C) 

2.  Other  facts  (if  any)  indicating   Insanity  communicated   to   me  by 
others  (*) 

[Signed) 

Place  of  Abode , — 


Dated  this        day  of  ,  One  thousand  eight  hundred  and 


SECOND  MEDICAL  CERTIFICATE. 

1 ,  the  undersigned,  being  a  (i)  ,  and  being  in  actual  practice 

as  a  (2)  ,  hereby  certify  that  1,  on  the  day  of  , 

at  (^)  ,  in  the  County  of  ,  ("*)  separately  from 

any  other  Medical  Practitioner,  personally  examined  (°)  , 

of  ,  and  that  the  said  is  a  (")  ,  and  a  proper 

Person  to  be  taken  charge  of  and  detained  under  care  and  treatment,  and 
that  I  have  formed  this  opinion  upon  the  following  grounds,  viz.  : 

1.  Facts  indicating  Insanity  observed  by  myself  C) 

2.  Other  facts   (if  any)  indicating   Insanity  communicated  to  me  by 
others  (*) 

{Signed) 

Place  of  Abode 


Dated  this         day  of  One  thousand  eight  hundred  and 

1  Here  set  forth  the  qualification  entitling  the  person  certifying  to  practise  as  a 
physician,  surgeon,  or  apothecary — e.g..  Fellow  of  the  Royal  College  of  Physicians. 
-  Physician,  surgeon,  or  apothecary,  as  the  case  may  be. 

^  Here  insert  the  street  and  number  of  house  (if  any)  or  other  like  particulars. 
■*  If  this  be  not  the  case,  erase  the  words. 

s  A B of  .    Insert  residence  and  profession  or  occupation  (if  any). 

^  Lunatic,  or  an  idiot,  or  a  person  of  unsound  mind. 

''  Here  state  the  facts. 

^  Here  state  the  Information  (if  any),  and  from  whom. 

Note. — Any  omission  in  respect  of  these  particulars  will  probably  render  the 
proceedings  invalid  and  the  confinement  illegal. 


LUNACY  FORMS  IN  USE  IN  IRELAND  477 

FORM  F. 

AGREEMENT  FOR  PAYMENT  AND  REMOVAL. 

To  the  Resident  Medical  Superinte?tdent,  District  Lunatic 

Asylum. 
Sir, 

In  consideration  of  your  receiving  into  and  maintaining  in  the 
above  Asylum  as  a  Patient,  I  hereby  agree  to  pay  at  the  rate 

of  £  per  annum,  payable  in  advance  by  half-yearly  instalments 

for  care  and  maintenance  therein,  until  discharged,  and  at  any 

time  on  receiving  notification  from  the  Inspectors  or  Board  of  Governors 
of  the  District  Lunatic  Asylum  that  the  above-named 

is  no  longer  a  fit  person  to  be  accommodated  therein,  I  hereby  undertake 
to  remove  from  the  Asylum  the  said  within  one  week  from  the 

date  of  receiving  such  notification  as  aforesaid  ;  and  if  not  so  removed 
within  a  fortnight,  I  hold  myself  responsible  to  the  Board  for  any  expense 
incurred  by  the  removal  of  said 

Dated  this  day  of  18        . 

Signature   

It  is  requested  that  a  person  will  accompany  the  Patient  to  the  Asylum 
who  will  be  able  to  give  the  best  information  respecting  the  disease, 
former  mode  of  life,  habits,  propensities,  etc. 


Special  Home  Treatment  for  Inebriates. 

The  patient  must  sign,  before  two  magistrates,  a  form  ex- 
pressing a  wish  to  enter  the  retreat.  Two  friends  must  sign 
a  declaration  that  they  consider  the  patient  an  '  inebriate ' 
within  the  meaning  of  the  Acts.  In  the  case  of  patients 
who  dechne  to  go  in  under  the  Act,  all  that  is  required  for 
them  to  do  is  to  make  a  written  request  signed  over  a  six- 
penny stamp. 


INDEX 


A 

Aboulia,  66 

Acrophobia,  66 

Adolescence,  insanity  of,  253 

clinical  illustrations  of,  271 
course  and  prognosis  of,  257 
division    into   three   classes, 

253 

symptoms  of,  254 

treatment  of,  258 
Agorophobia,  66 

Alcohol  as  a  cause  of  insanity,  281 
Alcoholic  dementia,  290 

clinical  illustrations  of,  307 

prognosis  and  treatment  of, 
291 

symptoms  of,  290 
Alcoholic  insanity,  280 

varieties  of,  283 
Alcoholic  insanity,  chronic,  288 

clinical  illustration  of,  306 

prognosis  and  treatment   of, 
291 

symptoms  of,  288 
Alcoholic  mania,  acute,  286 

clinical  illustrations  of,  301 

prognosis  and  treatment  of, 
286 

symptoms  of,  286 
Anaemia  in  insanity  of  lactation,  344 
Anergic  stupor  and  dementia,  distinc- 
tion between,  173 
Apperception,  15 
Artificial  feeding,  92 
Ascham,  Roger,  on  treatment  of  de- 
fective children,  415 
Asthma  in  relation  to  insanity,  361 

B 

Baillarger,  on  '  folie  circulaire,'  157 
on  melancholia  with  stupor,  108 
on  statistics  of  heredity,  72 

Baldwin,  illustration  of  weakness  of 
children's  memory,  12 


Ball,  on  general  paralysis,  197 

Bannister,  on  monomania,  159 

Bateman,    on    thyroid    treatment   of 
cretinoid  idiocy,  434 

Beach,     Fletcher,     on     setiology    of 
idiocy,  417,  419,  420 
on  data  of  the  feeble-minded,  392 

Bennett,    Hughes,    on   hysterical    in- 
sanity, 262 

Binz,  on  action  of  morphine  on  nerve 
cells,  173 

Blaise,  on  myxcedema  and  insanity, 

377 
Blandford,  on  insanity  of  pregnancy, 

315 
Bourneville,  on  microcephalus,  434 
Bright's  disease,  insanity  of,  362 

illustrations  of,  363 
Bristowe,  on  post-febrile  insanity,  381 
Bruce,  on  thyroid  treatment,  99 


Cadell,  his  case  of  syphilitic  insanity, 

296 
Cardiac  disease,  insanity  of,  364 
Catalepsy,  112 

Certificates  for  treatment  of  idiots  in 
special  institutions,  435 
of  insanity,  444 
of  sanity,  452 

of  testamentary  capacity,  454 

Charcot,  on  hysterical  insanity,  259 

Children,  mental  development  in,  9 

genesis  of  the  emotions  in,  11 

senses  first  in  evidence  in,  10 

Chloral    and   bromides   in   puerperal 

insanity,  338 
Chronic  alcoholic  insanity,  288 
Claustrophobia,  66 
Climacteric  insanity,  263 

clinical  illustrations  of,  276 
prognosis  and  treatment  of, 

265 
symptoms  of,  263 


48o 


CLINICAL  MANUAL  OF  MENTAL  DISEASES 


Clouston,  on   alcohol   as  a   cause  of 
insanity,  281 
on  anergic  stupbr,  173 
on  delusional  nlelancholia,  106 
on  diet  of  the  ihsane,  93 
on  epilepsy,  225-234 
on  '  folie  circulaire,'  158 
on  impulsive  insanity,  191 
on  insanity  of  Bright's  disease,  362 
on  insanity  of  diabetes,  366 
on  insanity  of  pregnancy,  313 
on  moral  insanity,  187 
on  phthisical  insanity,  378 
on  prognosis  of  insanity  of  adoles- 
cence, 257 
on  rheumatism  and  insanity,  384 
on  sense  of  Vv'ell-being,  17 
on  senile  insanity,  266,  269 
on  syphilitic  insanity,  394 

Consecutive  insanities,  360 

Circular  insanity,  157 

Cretinism,  430 

D 

Dagonet,  on  epileptic  seizures  due  to 

alcoholic  excess,  282 
Delirium  ebriosum,  283 
Delirium  tremens,  284 

clinical  illustrations  of,  193 
prognosis  and  treatment   of, 

286 
symptoms  of,  284 
Delusions,  in  mania,  151 
sane  and  insane,  51 
varieties  of,  55 
Dementia,  178 

clinical  illustrations  of,  193 
consecutive  and  organic,  179 
Dementia,  alcoholic,  290 
Dementia  and  anergic  stupor,  distinc- 
tion between,  173 
Development,  defects  in,  394 
Diabetes  and  insanity,  366 
Diet  of  the  insane,  93 
Dipsomania,  190,  287 

clinical  illustrations  of,  305 
Dissolution,  law  of,  22 


Echeverria,  on  marriage  of  epileptics, 

236 
Education  of  mentally  deficient  chil- 
dren, 414 
Environment,  law  of,  25 
Epilepsy  with  sanity,  222 
Epileptic  insanity,  223 
aetiology  of,  224 
clinical  illustrations  of,  237 
diagnosis  and   prognosis   of, 

233 
symptoms  of,  225 


Esquirol,  on  monomania,  126 
Evolution,  law  of,  22 
Examination  of  mental  cases,  445 
Exner,  on  the  law  of  mental  reaction, 

Exophthalmic  goitre  and  insanity,  367 


Faculties,  musical,  artistic,  etc.,  19 
Falret,  Jules,  on  chronic  progressive 
delusional  insanity,  130,  136 
on  epileptic  insanity,  229,  231 
on  '  folie  circulaire,'  157 
Finger,  on  syphilitic  insanity,  296 
Flechsig,    on   treatment   of  epilepsy, 

235 

Folie  circulaire,  157 

Foville's  migrating  insane,  132 

Foville,    on   chronic   progressive    de- 
lusional insanity,  134 

Fiirstner,  on  senile  insanity,  266 

G 

Garrod,  on  gout  and  insanity,  369 
General  paralysis,  causes  of,  igg 

clinical  illustrations  of,  217 

definition  of,  197 

differential  diagnosis  of,  213 

its  stages,  202 

mental  varieties  of,  207 

physical  signs  of,  208 

premonitory    symptoms    of, 
201 

prognosis  of,  215 

treatment  of,  216 
Gooch,  on  prognosis  in  puerperal  in- 
sanity, 332 
Gout  and  insanity,  268 
Gowers,  on  treatment  of  epilepsy,  235 
Greenlees,  T.  D.,  on  insanity  of  car- 
diac disease,  364 
Gull,  on  myxoedema  and  insanity,  376 

H 

Hasmatoma  auris,  97 

treatment  of,  98 
Hallucinations,  in  mania,  152 

sane  and  insane,  50 
Heredity,  68 

the  influences  of,  in  early  life,  249 
Hereditary  predisposition,  71 
Herter,  on  treatment  of  epilepsy,  235 
Hoche,  Ludwig,  on  puerperal  insanity, 

.328 
Homicide,  65 

Howden,  on  insanity  of  Bright's  dis- 
ease, 362 
Howe,  of  Boston,  on  case  of  Laura 

Bridgman,  431 
Horsley,  on  microcephalus,  434 
Humour,  sense  of,  19 


INDEX 


48 1 


Hydrocephalic  head,  396 
Hypochondriacal  melancholia,  106 

clinical  illustration  of,  115 
Hyslop,  on  general  paralysis,  197 
Hysterical  insanity,  251,  259 

prognosis  and   treatment  of, 
262 

I 
Idiocy,  416 

aetiology  of,  417 

by  deprivation,  431 

classification  of,  425 

diagnosis  of,  421 

eclampsic,  427 

epileptic,  427 

genetous,  425 

hydrocephalic,  with  illustrations, 
428 

inflammatory,  431 

microcephalic,  428 

paralytic,  430 

traumatic,  430 

treatment  of,  433 
Illusions,  sane  and  insane,  49 
Imbecility,  416 

aetiology  of,  417 

diagnosis  of,  421 

treatment  of,  433 
Impulsive  insanity,  189 

clinical  illustrations  of,  195 
Incoherence,  61 
Individuality,  law  of,  22 
Inebriates,    special    home    treatment 

for,  468 
Inebriety,  definition  of,  280 
Influenza,  insanity  of,  370 
Insane  ear,  97 

Insane  conduct  and  propensities,  63 
Insane,  classification  of  the,  loi 

general  treatment  of  the,  80 

method  of  examination  of  the,  84 
Insanity  of  adolescence,  253 

alcoholic,  280 

of  asthma,  361 

of  Bright's  disease,  362 

of  cardiac  disease,  364 

causation  of,  68 

chronic     progressive    delusional, 

climacteric,  263 

of  the  degenerate,  70 

of  diabetes,  366 

epileptic,  223 

of  exophthalmic  goitre,  367 

general  principles  of  treatment  of, 

80 
of  gout,  368 
hysterical,  259 
impulsive,  189 
of  influenza,  370 
of  lactation,  340 


Insanity  of  lead-poisoning,  372 
of  masturbation,  180 
due   to   menstrual   irregularities, 

373 

moral,  186 

of  myxcedema,  376 

of  phthisis,  378 

post-febrile,  381 

of  pregnancy,  313 

prognosis  in,  75 

of  puberty,  249 

puerperal,  311,  317 

of  rheumatism,  384 

senile,  266 

of  sunstroke,  386 

syphilitic,  294 

of  uterine  disease,  387 
Insomnia,  36 

causes  of,  37 

treatment  of,  39 
Ireland,   on  aetiology  of  idiocy,   418, 
419 

on  classification  of  idiots,  425 

on  eclampsic  idiocy,  427 

on  inflammatory  idiocy,  431 

on  sane  hallucinations,  51 

on  traumatic  idiocy,  430 

on  varieties  of  palate,  401 

.    J- 

Jackson,  Hughlings,  on  epilepsy,  225 

on  moral  insanity,  187 
Johnstone,  Carlyle,  on  exophthalmic 
goitre  with  mania,  367 

K. 

Kahlbaum,  on  katatonia,  iii 

Katatonia,  iii 

Keen,  on  microcephalus,  434 

Kerr,  Norman,  on  the  inebriate,  280 

on  opium-eating,  293 
Kirchner,  '  Manual  of  Psychology,'  20 
Kirn,  on  insanity  of  influenza,  371 
Kleptomania,  63,  190 


Lactation,  insanity  of,  340 

aetiology  of,  341 

clinical  illustrations  of,  356 

prognosis  and  treatment  of,  346 

symptoms  of,  342 
Ladd,  '  Physiological  Psychology,'  20 

on  the  law   of  mental   reaction, 

Langdon  Down,  on  aetiology  of  idiocy, 

417.  419 
on    data  of    the    feeble-minded, 

392 
on  Mongolian  idiots,  432 
on  varieties  of  teeth  and  palates, 

400,  401 
Lannalongue,  on  microcephalus,  434 

31 


482 


CLINICAL  MANUAL  OF  MENTAL  DISEASES 


Laseque,    on    chronic   delusional    in- 
sanity, 128 

on  insanity  of  diabetes,  366 

on  partial  insanity,  127 
Law  as  to  treatment  of  single  patients, 

449 
Law  of  interference  with  a  lunatic's 

property,  452 
Laycock,  on  abnormal  ears,  398 

on  kleptomania  in  pregnancy,  314 
Lead-poisoning  and  insanity,  372 
Legrain,  on  insanity  of  the  degenerate, 

70 
Lewis,  Bevan,   on   general  paralysis, 

208 
Lunacy  forms  in  use  in  England,  457 
Lunacy  forms  in  use  in  Ireland,  468- 

478 
Lunacy  forms  in  use  in  Scotland,  461 
Lunatics,  evidence  of,  443 
Lyman,  on  sleep,  35 

M. 
Macdonald,  on  responsibility,  442 
McDowall,  on  insanity  of  lead-poison- 
ing, 373 
Maclaren,  on  impulsive  insanity,  191 
Macphail,  on  treatment  of  anaemia  in 

insanity  of  adolescence,  258 
Macpherson,  J.,  on  chronic  delusional 
insanity   of    systematic   evolu- 
tion, 127 
on    Raynaud's   disease    with    in- 
sanity, 383      _ 
Magnan,    on   chronic    delusional   in- 
sanity of  systematic  evolution,  127- 

133 
Mania,  acute  alcoholic,  286 
acute  delirious,  155 
acute  and  subacute,  149 
setiology  of,  i5q 
'  a  potu,'  283 
chronic,  156 
•    clinical  illustrations  of,  164 
description  of,  145 
'  folie  circulaire,'  157 
mental  symptoms  in,  150 
physical  conditions  in,  153 
prognosis  in,  160 
recurrent,  156 
simple,  149 
treatment  of,  161 
Marie,  on  chronic  delusional  insanity 

of  systematic  evolution,  127 
Masked    epilepsy    of     Esquirol     and 

Morel,  228 
^Masturbation,  insanity  of,  180 

clinical  illustrations  of,  193 
symptoms  of,  181 
treatment  of,  185 
Maudsley,  on  insanity  of  diabetes,  366 
Megalomania,  134 


Melancholia,  103 

acute,  104 

aetiology  of,  121 

chronic,  108 

clinical  illustrations  of,  112 

delusional,  106 

differential  diagnosis  of,  122 

hypochondriacal,  106 

neuralgic,  104 

physical  symptoms  of,  107 

resistive,  107 

senile,  108 

silent,  107 

simple,  103 

with  stupor,  108 
Menstrual  irregularities  and  insanity, 

373 
Mental  character,  the  physiology  of 

mind, 21 
Mental    constitution,    its    component 

parts,  14 
Mental  development  retarded  or  im- 
paired, 391 
signs  of,  393 
treatment  of,  414 
Mental  disease,  legal  and  civil  aspects 

of.  438 
Mental  health,  27 
Mental  hygiene,  30 
Mercier,    '  Lunacy  Law   for   Medical 

Men,'  452 
Mickle,  Julius,  on  general  paralysis^ 
199,  207 
on   insanity    of   cardiac    disease, 

364 
Alicrocephalic  head,  396 
Monomania,  125,  159 
Moral  insanity,  186 

clinical  illustrations  of,  194 
Mosso,  of  Turin,  on  sleep,  35 
Murchison,   on    post-febrile   insanity, 

381 
Myxoedema  and  insanity,  376 

N. 
Nasse,  on  post-febrile  insanity,  381 
Neuralgic  melancholia,  104 
Nevdngton,    on   anergic    stupor,    173, 
176 
on  refusal  of  food,  79 
Norman,     Conolly,    on     insanity     of 
asthma,  361 

Obsession,  65 

of  greatness,  134 
of  persecution,  129 
Opium   indulgence,    clinical    illustra- 
tion of,  308 
Opium,  nervous  and  mental  effects  of, 

292 
Ord,  on  myxoedema  and  insanity,  376 


INDEX 


Palate,  varieties  of,  402 

Paralysis,  general,  197 

Paranoia,  125,  159 

Percy,  Baron,  on  aetiology  of  idiocy,  420 

Phthisis  and  insanity,  378 

Playfair,  on  insanity  of  lactation,  340 

Post-febrile  insanity,  381 

Pregnancy,  insanity  of,  313 

causes  of,  314 

clinical  illustrations  of,  347 

forms  of,  313 

symptoms  and  prognosis  of, 

315 

treatment  of,  316 
Preyer,  on  memory  of  children,  12 
Pritchard,  on  moral  insanity,  186 
Puberty,  insanity  of,  249 

clinical  illustrations  of,  269 

prognosis  and  treatment  of, 
252 
Puerperal  insanity,  311,  317 

aetiology  of,  330 

bodily  symptoms  of,  328 

causes  of,  317 

clinical  illustrations  of,  349 

mental  symptoms  of,  321 

prognosis  of,  332 

treatment  of,  333 
Pyromania,  63,  190 

R. 

Raynaud's  disease  in  relation  to  in- 
sanity, 382 
Rayner,  Henry,  on  gout  and  insanity, 

369 
on  insanity  of  lead-poisoning,  372 
Regis,  on  insanity  of  diabetes,  366 
on  insanity  of  pregnancy,  313 
on  loss  of  will,  66 
on  melancholia  with  stupor,  108 
on  syphilitic  insanity,  294 
Responsibility,  the  question  of,  438 
Reynolds,   Russell,   on  gout  and   in- 
sanity, 368 
Rheumatism  and  insanity,  384 
Richet,  on  processes  of  digestion,  91 
Ritchie,  Peel,  on  insanity  of  mastur- 
bation, 180 
Robertson,  Alex.,  on  delirium  tremens, 
284 
on   epileptic  seizures  caused   by 

alcoholic  excess,  282 
on  hallucinations  in  alcoholic  in- 
sanity, 283 
on  insanity  of  lead-poisoning,  372 
on  treatment  of  status  epilepticus, 
236 
Ross,  on  speech  in  epileptic  insanity, 

223 
Ruxton,  on  insanity  of  lead-poisoning, 
372 


Savage,  on  alcohol  as  a  cause  of  in- 
sanity, 281 
on  anergic  stupor,  176 
on  epileptic  automatism,  229 
on  epileptic  insanity,  223 
on  general  paralysis,  198,  201 
on  insanity  of  asthma,  361 
on  insanity  of  diabetes,  366,  367 
on  insanity  of  lactation,  342,  344 
on  insanity  of  pregnancy,  313 
on  moral  insanity,  187 
on  partial  insanity,  125 
on  rheumatism  and  insanity,  384 
on  senile  insanity,  266 
on  case  of  syphilitic  insanity,  296 
Seguin,  on  definition  of  idiocy,  416 
Senile  insanity,  266 

aetiology,  prognosis,  and  treat- 
ment of,  269 
clinical  illustrations  of,  279 
symptoms  of,  267 
varieties  of,  266 
Sense  perception,  15 
Shaw,  Claye,  on  the  palate  in  idiots, 

401,  402 
Shuttle  worth,  on  aetiology  of  idiocy, 
417,  419 
on    data    of    the    feeble-mmded, 

392 
on  defects  of  nutrition,  407 
on  treatment  of  defective  children, 
414 
Sibbald,  on  dipsomania,  287 

on  epileptic  automatism,  229 
Simpson,  on  puerperal  insanity,  328 
Skae,  on  post-febrile  insanity,  381 

on  uterine  disease  and  insanity, 

389 
Sleep,  ^3 

Smith,  on  treatment  of  epilepsy,  235 
Spencer,  on  moral  insanity,  187 
Spitzka,  on  general  paralysis,  199 

on  senile  insanity,  266 
Stephen,  Mr.  Justice,  on  responsibility, 

441 
Stockvis,  B.,  on  the  use  of  sulphonal, 

45 
Stupor,  173 

clinical  illustrations  of,  192 

melancholic  and  anergic,  174 

treatment  of,  178 
Suicidal  propensity,  64 
Suicide,  methods  of,  64 
Sunstroke  and  insanity,  386 
Sutherland,   Henry,    on   kleptomania 
in  pregnancy,  314 

on  prognosis  in  the  insane,  79 
Syphilitic  insanity,  294 

clinical  illustration  of,  308 

prognosis  and  treatment  of,  299 

varieties  of,  295 

31—2 


DATE  DUE 


N0\  -  4  mi 


i%\ji    ^ 


Demco,  Inc.  38-293 


VKIES 

01    8' 

row 


COLUMBIA  UNIVERSITY  LIBRARIES 


0052802752 


RG602 


C55 
1898 


Clark 

Clinical  raarmal  of  mental 

diseases.  


U02- 


CST 


